Optimizing Unilateral Electroconvulsive Therapy

Review of the unilateral-bilateral literature cannot identify the factors that optimize the efficacy of right unilateral electroconvulsive therapy (ECT) (RUL), and we should not confuse hunches with facts. With the exception of stimulus dosing, there is little experimental support that the conditions suggested by Dr. J.-O. Ottosson affect RUL efficacy. The theoretical position that eliciting a full, maximally generalized seizure provides the basis for optimal efficacy also lacks experimental support and is imprecise. Further, the conditions proposed to optimize RUL efficacy also augment its side effect profile. We do not know whether an optimal form of RUL will retain cognitive advantages if compared to optimal bilateral ECT. We also lack a clinically useful marker that an optimal form of RUL has been delivered. Under these conditions, it seems appropriate that the choice of electrode placement be made on an informed case-by-case basis.