Electroconvulsive therapy (ECT) is often regarded by the general public as a controversial procedure for the treatment of mental disorders. This is despite evidence of its safety and efficacy [1
], and its benefit over anti-depressants in patients resistant to conventional medications and those with life threatening conditions such as catatonia and depressive stupor. The evidence suggests that in unipolar depression ECT has better efficacy when compared with older tricyclic antidepressants and monoamine oxidase inhibitors, as well as newer drugs such as paroxetine [2
]. Notwithstanding the efficacy of ECT, its use is declining in some countries [3
], while in a few others, including Italy – where ECT was first introduced in 1938 by Cerletti and Bini – it is prohibited. Aside from political reasons and public pressure, the declining trend in ECT use could be the result of the introduction of more effective antidepressants.
A further possible explanation for the reduction in ECT use may relate to the concern over adverse effects of the procedure. There are a number of short-term side effects including headache, nausea and, sometimes, brief confusion. However, the main side effect of concern is memory impairment for past events (retrograde amnesia) and for current events (anterograde amnesia) that can last for several months after a course of ECT treatment. Some of these side effects are substantially reduced by advances in safety and the introduction of controlled-current ECT machines. The utilisation of muscle relaxants, anaesthetics and resuscitation equipment, and electroencephalographic monitoring during the application of ECT are considered now considered routine. In addition, ECT guidelines issued by the UK National Institute for Clinical Excellence [4
] restrict the use of ECT only to patients with severe symptoms to which "an adequate trial of other treatment options has proven ineffective" (p. 5). The risk associated with ECT has also been reduced with the introduction of refined ECT procedures, such as "maintenance ECT" or "unilateral ECT" (uECT) [5
It has been suggested that unilateral treatment significantly reduces side effects, especially memory disturbances [6
]. Despite the well-documented efficacy of unilateral over bilateral ECT, current practice still favours bilateral treatments [8
]. Unilateral treatment, for the majority of patients, entails that electrodes are placed over the non-dominant, right hemisphere. Given that memory impairment could be reduced by unilateral electrode placement and the fact that placement of electrodes to the dominant hemisphere may cause a greater disturbance in memory compared to non-dominant uECT, determination of cerebral dominance appears to be critical [10
]. It is important to note that cerebral dominance here equates to speech dominance, including a lateralised capacity of the cortex to be the locus of language-specific memory traces [11
]. Avoiding the stimulation of the speech area will therefore reduce speech dysfunction after ECT. Traditionally, the routine clinical determination of cerebral dominance has been through the assessment of hand, foot and eye dominance. It certainly is an easy and inexpensive approach, but it does not ensure accuracy.