Systematic review and meta-analysis of bifrontal electroconvulsive therapy versus bilateral and unilateral electroconvulsive therapy in depression

Objectives. Our aim was to perform a meta-analysis of randomized controlled trials comparing efficacy and side effects of bifrontal (BF) ECT to bitemporal (BT) or unilateral (RUL) ECT in depression. Methods. We performed a systematic review of randomized controlled trials comparing BF ECT with RUL or BT ECT in depression. Eight trials (n = 617) reported some cognitive outcome. Efficacy was measured by reduction in Hamilton Depression Rating Scale score. Cognitive outcomes were limited to Mini-Mental State Examination (MMSE) in seven studies, with two studies measuring each of: Complex-figure delayed recall, Trail-making tests and verbal learning. Results. Efficacy was equal between BF and BT ECT (Hedges's g = 0.102, P = 0.345, confidence interval (CI): -0.110, 0.313) and BF and RUL ECT (standardized mean difference - -0.12, P - 0.365, CI: -0.378, 0.139). Post-treatment MMSE score decline was less for BF than BT ECT (g = 0.89, CI: 0.054, 1.724) but not RUL ECT. RUL ECT impaired Complex figure recall more than BF ECT (g = 0.76, CI : 0.487, 1.035), but BF ECT impaired word recall more than RUL ECT (g = -1.45, CI: -2.75, -0.15). Conclusions. Bifrontal ECT is not more effective than BT or RUL ECT but may have modest short-term benefits for specific memory domains. BF ECT has potential advantages, but given longer experience with BT and RUL, bifrontal ECT requires better characterization.