Unilateral Versus Bilateral ECT in Schizophrenia

D. R. DOONGAJI, D. V. JESTE, N. J. SAOJI, P. V. KANE and S. RAVINDRANATH

BJP 1973, 123:73-79.
Access the most recent version at DOI: 10.1192/bjp.123.1.73

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Brit. 3. Psycliiat. (i97@), 123, 739

Unilateral
By D. R. DOONGAJI,

Versus Bilateral ECT in Schizophrenia

D. V. JESTE, N. J. SAOJI, P. V. KANE

Electroconvulsive
therapy
with unilateral
electrode placement has been tried most often
in depressive disorders (Abrams and de Vito,
1969; Cannicott,
1962; Cannicott and Wag
goner,1967;Costello
cial.,1970;d'Ella,1970;
Fleminger

ci al., 1970; Levy,

1968; Martin

ci a!.,

1965; Strain ci a!.,1968; Valentine ci al.,1968;

Zinkin
1958),

and Birtchnell,
1968; Lancaster
ci a!.,
although
Lancaster
(op. cit.) noted that

the comparative

results in schizophrenia

15 and 45 years

of age were included. Before admission to trial

two clinicians independently diagnosed them as
schizophrenics on separate occasions. None of
thepatients
had receivedany form ofpharma
cological, physical or psychotherapeutic
treat
ment for a minimum period of three months
prior to the study. Patients who had shown
symptoms

Subjects

were

3I to 45 years) and duration of illness (i month

to I year/13

months

to 2 years)

and allotted

to

one of the three treatment

modalities,
viz.
unilateral
dominant
(UD), unilateral
non
dominant (UND) or Bilateral (BIL) ECT using

placements.

For the unilateral

of separate

hand-held

instead

SUBJECTS

sexes between

1962).

to age range ( 15 to 30 years/

of the

usual

treatment,

electrodes
forceps

type

a pair

was devised
electrodes.

The electrodes were 2 5 @,ffjin diameter and

were placed 8 . 5 cm. apart ; the lower one 4 cm.
above the line joining the lateral orbital angle
and the external auditory meatus, the upper one
8 cm. distant at an angle of 70 degress. No
anaesthesia or preanaesthetic
medication was
used.
Treatments were given thrice weekly for the

The sample consisted of 86 patients who

attendedthe out-patient
services
of the King
Edward
VII Memorial
Hospital,
Bombay.
of both

Gorham,

The three forms of ECT were administered

under identical conditions using a fixed voltage
setting of I 20 volts and standard
electrode

of bilaterally
administeredECT and of ECT
administered unilaterally to either the dominant
or thenon-dominanthemisphere.

Patients

and

grouped according

randomization.

it was as effective as bilateral ECT in relieving

certain other psychotic symptoms,
such as
catatonia, stupor and hallucinations. This paper
reports

(Overall

and S. RAVINDRANATH

first two weeks and twice weekly for the next

two weeks. A minimum
of six treatments
were

administered.
Treatments
were discontinued
when it was felt that maximum therapeutic
benefit had been achieved. Patients reporting
progressive

but

partial

improvement

were

continued beyond ten electroconvulsive

treat
ments.The total
number oftreatments
and their
frequency were decided by the evaluating
physician.
The severity
ofsymptoms was on each occa

and signs of the disease for less than

one month or more than two years were not

selected, neither were those who had physical
abnormalities
liable to influence the outcome
of the trial.

sion evaluated by a global clinicalimpression

and by the BPRS

PROCEDURE

scores.Simultaneously,
a

clinical
assessmentof memory impairment and
confusion
was made. This was done initially
after six treatments
(Period I), and after the

Patients on trial were assessed for cerebral

dominance using the laterality tests described
by Zamora and Kaelbing (1965).Only right last treatment (Period II). The initial evaluation
handed patientswere chosen for treatment. was done 24 hours before ECfl', while the
The initial
pathologyineach casewas recorded subsequent evaluations at Periods I and II were
using the Brief Psychiatric
Rating Scale (BPRS)
done 24 hours afterECT. On discontinuing
73

UNILATERAL

74
treatment,

patients

were followed

weeks for a period

progress

The

VERSUS BILATERAL

up every

of three months

progress

of each

physician

physician
patient,

was blind'to the

while

TArn2 II

two

and their

was recorded.

treating

ECT IN SCHIZOPHRENIA

Analysis

administered.

No concurrent
medication
was permitted
throughout the trial period, except for chloral
hydrate 900 mg. t.d.s.

scores

UNDUDBILNumber

the evaluating

was blind'to the type of treatment

of total BPRS

of patients

..

Mean number of ECTs

Mean
38.7S.D.initial BPRS scoreI

38-6i8

..
..
..
7.468Mean

score(Period
second BPRS

9 4

40@3@g

..24@928@925@9S.D.
I)
..

..
..
..
71I3@24@4Mean
score(Period
final BPRS

RESULTS

The results are reported

patients
initially
included

for 54 out of 86
in the trial. The

..25@630.726@IS.D.
II) ..
..
..

..io'613675

remaining32 patients
were not includedin the variance carried out with one way classification
analysis, as they failed to receive a minimum of did not give a signifIcant F'
value to reject the
six treatments.
hypothesis of equality between the treatment
Generalized
grand
mal convulsions
were
effects.
elicited on all treatment
occasions in all
The population was dichotomized into two
instances. Table I shows the descriptive charac
groups ; a reduction of @oper cent or more in
teristics of the sample population.
the initial scores was the basis for this division.
Tables

T@rn@I
Descriptive characteristicsof sample population
UND

UD

BIL

III and IV show this distribution

significant

difference

between

the three

any
treat

ment conditions.

Number
patients..17i819Males
of

T@trn.nIII

....u68Females
....612IIMean
(years)..2525@928-2Mean
age

for the

three different treatment conditions.

The Chi square test did not suggest

Improvement
(50

per

cent

reduction

in score

at Period

I)

duration(months)5.754.758

TotalImprovedUND
..
scores
Not improved
All results are reported at the 5 per cent level
of significance throughout
this study. The t'
statistic calculated to find differences between
the three treatment conditions was not signi
ficant in any case, the improvement
being
equally significant in all the three treatment
Analysis of total BPRS

modalities.

The higher standard deviation in the UD

group compared to the others for the second
(Period I) and the third scores (Period II)
shows the inconsistency of the improvement
rate within this group. The other two groups
have almost the same pattern of improvement

(50

per

13
i617
4

BIL
13
6

38

19

IVImprovinent

cent II)UND
reduction

..

12
6

54TABUI t8

TotalImproved
Not improved

UD

14
i817
3

in score

at Period

UD

BIL

10

12

i8

36

ig

(Table II).
An@c
ofscorcs ofindividual variables of BPRS
The data were analysed taking the differences
The individual
scoresof the i8 variables
of
between the initial
scoresand between the
the BPRS were analysed for within group
second and third scores separately.
Analysis of

BY D. R. DOONGAJI,

D. V. JESTE, N. J. SAOJI, P. V. KANE AND S. RAVINDRANATH

differences after 6 ECTs (Period I) and after the

last ECT (Period II) using Wilcoxon's matched
pairs signed-ranks test (Siegel, 1956).
For i 2 out of the i8 BPRS variables, where
significant reduction in scores was demonstrated
by Wilcoxon's test at either or both periods for
more than one treatment condition, the change
scores were analysed for between-treatment
preferences
by the Mann-Whitney
U test
(Siegel,
1956).
The results of both these analyses are shown
in Table V.
The

variables

guiltfeelings',

@.emotionai withdrawal',
cinatory
behaviour',

to remain

tension' and

so during

the

course

suspiciousness', hallu
uncooperativeness'
and

excitement'.All three treatment conditions also

significantly reduced the scores for conceptual
disorganization'
at Period I. However, this
effect did not persist at Period II when none
of the three treatments
showed significant
effectiveness. All three treatments were effective
at both periods for unusualthought content'
except in the case ofUND ECT, where it failed
to reach significance at Period I.
BIL ECT and UD ECT gave significant
results

grandiosity' did not enter into the analysis

because the initial scores were normal and they
continued

75

of

treatment.

The Wilcoxon's test showed that the reduction

in scores was not significant at either period for
any of the three types of ECT for somatic
concern' and disorientation'. BIL ECT alone
was significantly
effective
forblunted
affect'
at
Period I, but not at Period II.
All threetreatmentconditions
showed signi
ficantreductionin scoresat both periods,for

at

both

periods

for

mannerisms and

posturing'.
Both UND ECT and BIL ECT gave signi
ficant results at both periods for hostility'and
motorretardation'.
For the variable anxiety',
UND ECT was significantly effective at both
periods while BIL ECT was significantly
effective only at Period II. For the variable
depressedmood', BIL ECT was significantly
effective at both periods, while UND ECT was
significantly effective only at Period I.
The U'test showed that for the variable
conceptual disorganization'
UND ECT and

T4@nu@V
Analysis of scores of individual variables of BPRS

BPRS variablesUNDUDPcBIL
HSomatic

____________Period

....n.s.n.s.n.s.n.s.n.s.n.s.Anxiety
concern ..
..
..
..
sConceptualwithdrawal
Emotional
....
disorganization
Guiltfeelings
..
..

IPeriod

IPeriod

IIPeriod

IInod

IPeriod

..s

ss

sn.s.

sn.s.

sn.s.

ss

..5*

*
*n.s.

*
*S

*
*fl.S.

*
*S@

*
*fl.S.

*Mannerisms ....
Tension

and posturing

Grandiosity
..
Depressed mood ..

..
..

Hostility
..
Suspiciousness

..
..

Hallucinatory

..
..

..
..

behaviour

. ...

..
Unusual thought content
n.s.Excitement
Blunted
affect
..
. ..

Significant

..
..
at

. ..
. ..
P

. .

. .

sUncooperativeness
Motor retardation

.sssSSSDisorientation

. .

<

005

n.s.

n.s.

n.s.

n.s.

n.s.

S
s

S
s

s'@

s@
s@n.s.

. .n.s.

ss

n.s.s

n.s.s

s
n.s.s

s
n.s.s

ss@

.
. .
. .s

n.s.
n.s.s

s
n.s.s

s@
sS

.n.s.n.s.n.s.n.s.n.s.n.s.

(Wilcoxon's

test).

n_s. = Not significant (Wilcoxon's test).

@

*
5*

= Not computed
as scores showed
no pathology
initially
or at periods
Preferred
treatment
at P < o 05 (Mann-Whitney
U-test).

I and

II.

UNILATERAL VERSUS BILATERAL ECT IN SCHIZOPHRENIA

76

BIL ECT were preferred to UD

I. Preference in favour of UND
demonstrated
at Period I for
hostility',suspiciousness' and
behaviour',

while

BIL

ECT

ECT at Periol
ECT was also
the variables
hallucinatory

was preferred

for

the variable unusualthought content' at this

period. At Period II, UND ECT was still the
preferred

treatment

for suspiciousness', while

BIL ECT was preferred

for mannerismsand

posturing'.

were

At

no

time

ferences demonstrated

significant

TABLE

VI

Double-blind guesses of type of ECT administered

of
Number of
guessesUND

of

correct

incorrect

patientsNumber guessesNumber

UD..
i810
ioBIL..19127543024

87

..17

pre

in favour of UD ECT.
p =

00004

Memo@y-impairmcnt and confusion

Before the code was broken, the evaluating

physician, who was blind'to the type of treat
ment, tried to guess the type of ECT on the
basis of memory involvement and confusion.
These guesses were based on Halliday's observa
tions about

the effects ofECT

on verbal memory,

that UD ECT was associated with the most side

effects, while UND ECT was associated with the
least amount ofside effects, BIL ECT occupying
an intermediate position (Halhiday et a!., 1968).
On this basis, when the side effects were
judged to be markedor definite' the guess was
for unilateral dominant ECT; when they were
moderate',for bilateral ECT ; while unilateral
non-dominant ECT was the guess in cases where
the side effects were mild
or negligible'.
Table VI shows that 30 guesses were correct.
Out of a total of 54 patients, with three alter
native possibilities per patient, the probability
of 30 being correct by random assignment is
@

0004.

occurred

The

likelihood

by chance

that

is quite

this

could

have

remote.

Follow-up
Follow-up data at the end of three months
were available in 46 out of the 54 C@SCS
On trial
(85 per cent).
Table VII shows the state of the patients at
the time of follow-up.
The Chi square test showed no significant
differences

between

the three

teatment

condi

tions at the time of follow-up.

DiSCUSSION

More than twenty papers have been published

on unilateral electroconvulsive
therapy during
the last fifteen years. The majority of these

TAinx VII
Results at time offotlow-up (end of three months)
TotalTotal
number

data

of

not

number

availableTotal
improvedUND
patientsFollow-up
improvednumber
i8
UD
BIL7 II54462125
19i6

15

159

47

reports

on

are

either

patients

diagnosed

as

depressive states or on diagnostically

hetero
genous populations (Abrams, 1967; Bilkiewicz
and Kryzowski, 1964; Impastato and Karliner,
ig66 ; Sutherland ci a!., 1969) . This hospital's
medical

records

show that about

25 per cent of

the total psychiatric

attendance
consists of
schizophrenics
(Table VIII). For the sake of
economy of time, finance and staff, schizo
phrenia is routinely treated in this department
with tranquilizers
and ECTs rather than by
supportive
psychotherapy.
Approximately
10,000

ECTs

are

administered

every

year,

the

T@u@ VIII
Attendance during the lastfweyears at
Department of P@ychiatry
of

of

ECT's1966
phreniaDc pressionNumber
patientsSchizo
YearNumber
1,183

1967
5,334
i@,i8o1969
ig685,387 5,8851,189

1,240559

549
6407,780

19705,5625,8771,191

1,204598

63311,12011,190

9,150

BY D. R. DOONGAJI,

D. V. JESTE,

N. J. SAOJI,

majority for schizophrenia ; hence the import

ance of conducting this study.
As seen in Tables

I and II, the treated

I 969

popula

tion seemed evenly matched for age, duration

of disease and initial pathology. Patients were
not matched for sex, as except for May's obser
vation
(May
ig68),
there
is no other
evidence

that

male

schizophrenics

respond

differently to ECT compared to females, or that

sex is an important prognostic factor influencing
the disease process (Astrup et al., 1962 ; Lang
feldt, 1956).
A three-month period of absence of treatment
of any

kind,

was

thought

ensure that the effects of

not materially
influence
series. In order to simplify
on the correct side of the
treatment,

only

to be sufficient

to

prior treatment did

the results in this
electrode placement
head at the time of

right-handed

patients

were

selected for this study.

The trial was conducted on an out-patient
basis rather than on admitted patients, as the
awareness of memory disturbance may depend
on the patients' circumstances and environment.
Out-patients would be more likely to complain
of disturbance in memory rather than hospita
lized patients

because

more

demands

would

P. V. KANE

be

made on their retaining powers outside the

hospital (Zinkin and Birtchnell, 1968). With
lesser voltage, generalized bilateral convulsions
were not induced in all instances; treatments
were therefore carried out at a uniform voltage

; Zamora

AND
and

S. RAVINDRANATH
Kaelbing,

i 965).

77
This

scale

was not found to be particularly useful in this

series, as testing the memory in a scattered
schizophrenic
raises more
problems
than
memory testing in a depressed patient. Most of
the patients

were illiterate

or semi-literate,

and

certain items on the scale like North',South',

etc. and items for assessing general knowledge
were not very meaningful
or applicable
(Wechsler,

that

I 945) . d'Elia

this scale mainly

learning.

( 1970)

For these reasons,

that was adopted

Analysis

states

further

gives an estimate
the simple

of

method

seemed more practical.

of the results

at the time of termina

ton of the treatment showed that there were

no differences among the three different treat
ment conditions
in the number
of ECfl's
required. (As a matter of fact BIL ECT re
quired a larger mean number of ECTs than
the other two, although the difference was not
significant.)
The same findings have been
reported
1970;
I 968

by

various

Fleminger
; Martin

ci
ci

a!.,

authors
a!.,

1970;

1965

(Costello
Halliday

; McAndrew

ci al.,
ci

al.,

ci

al.,

1967 ; Sutherland ci a!., 1969 ; Valentine ci a!.,

1968; Zinkin and Birtchnell, 1968). Bidder ci a!.
(97),Cannicott
(1962), d'Elia (1970) and
Strain ci a!. (i988) have reported that a larger
mean number of ECTs were required when the
treatments

were

carried

out

under

unilateral

conditions.
Except for Strain's report, this
difference in the number of ECTs required has
of 120.
not been significant.
Two independent
BPRS ratings for each
It has also been mentioned that increase in
patient would have increased the reliability of the number of ECTs increases the amount of
the scores. It is probable, however, that in this risk involved in the treatment
procedure.
study the reliability of the scales was not lower
Kalinowsky states that the risk for ECT is
than the reported values, where paired inde
between o o6 per cent and o o8 per cent
pendent ratings yielded correlations from o@@6 (Kalinowsky and Hippius, 1969). He also men
to 0-87 (Lyerly et al., 19501964). Moreover,
tions that in unpremedicated
ECT it is even less.
the physician who treated each patient remained
It is therefore, debatable as to how much is the
the same throughout,
and the physician who
actual increase in the risk involved with uni
evaluated the patients also remained the same
lateral ECT as compared to bilateral ECT,
throughout except that he had no knowledge
especially when the difference in the number of
of the treatment modality.
treatments under these two conditions is not
Many studies reporting memory involvement
significantly large and if unpremedicated
treat
and disorientation
with unilateral ECT have
ments are administered, as is the routine in this
been done on depressed
patients
using the
hospital.
Wechsler Memory Scale (Abrams, 1967; Levy,
No significant differences in the reduction in
1968; Martin ci a!., 1965; Sutherland
ci al.,
the total BPRS scores between the three different

UNILATERAL

78

VERSUS

BILATERAL

treatments
could be demonstrated
at either
period of assessment, except for the higher
standard deviation in the UD group compared

6 ECTs and after the last ECT. Treatments and

assessments
for efficacy and side effects were

to the others, indicating

The overall therapeutic

improvement
differences

the inconsistency

of the

within this group. There were no

between

the three groups at follow-up

which was done three months later.

From Table V, it seems that somatic
concern'
and disorientation' are not altered by any type
of ECT. It also seems that affectual flattening
fails to respond except to BIL ECT during the
early part of treatment.

ECT IN SCHIZOPHRENIA

For the 2 variables, where more than one

treatment
showed a significant reduction in
scores at either or both periods, the U-test
revealed preference for UND ECT at both
periods for suspiciousness',and also for hostility'
and hallucinatory behaviour'
at Period I
(Table V). This suggests that UND ECT might
most effectively alter paranoid symptoms of
schizophrenia, at least during the early course
of treatment.

UD

ECT

was

not

preferred

at

either period for any of the variables, and

therefore it probably does not have anything
more to offer than the other two types of ECT
as far as individual symptom-relief is concerned.
The above findings agree with Fakhr El
Islam ci a!'s. (1970) observations that UND ECT
was as effective as BIL ECT in relieving schizo
phrenic hallucinations and delusions. They do
not lend support to the theory that the amnesic
effects produced
by ECT are essential in the
treatment
of schizophrenic
and paranoid
psy

choses (d'Elia, 970;

Ottosson, 1968).
Since no differences were found between
UND, UD and BIL ECT as far as overall
therapeutic efficacy was concerned, while at the
same time UND ECT was associated with the
least amount
of memory
submitted
that UND ECT
choice for schizophrenia.

impairment,
it is
is the treatment
of

electroconvulsive

electrode
dominant,

therapy

under

double

blind

conditions.

results at the time of

termination
of treatment
and at the time of
follow-up
after three months showed that all
three treatment
conditions
were almost equally

effective. Unilateral
preferable

non-dominant

to unilateral

ECT seemed

dominant

ECT

randomization
using

and bi

lateral ECT during the early course of treatment

for paranoid symptoms.
Unilateral non-dominant
least side effects.

ECT produced

the

Aciiowi@oos@iau-rs
The authors thank Dr. N. S. Vahia, Professor and Head,

Department of Psychiatry, and Dr. T. H. Rindani,

Dean, K.E.M. Hospital and G.S. Medical College for
permission to conduct and publish this research.
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and DE VITO, R. A. (i98g). Clinical

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ASTRUP,

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and

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L.

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G.

(1970).

Comparison

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out

therapy with unilateral

and bilateral
II. Therapeutic efficacy in endogenous

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with

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BY D. R. DOONGAJI,

D. V. JESTE,

N. J. SAOJI,

HALLWAY, A. M., DAVISON, K., BROWNE, M. W., and

KRIGOER, L. C. (1968). A
comparison
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A synopsis of this paper was published in the November 1972 Journal.

D. R. Doongaji,

M.D., M.S.(Minn),M.A.M.5.,M.R.C.Psych.,D.P.M., Honoraiy Associate Professor,

D. V. Jeste, M.D., D.P.M., Honorary Assistant Professor,

Department of Psychological Medicine, King Edward
Medical College, Bombay, 12, India

VII Memorial Hospital and Gordhandas Sunderdas

N. J. Saoji, M.D., D.P.M., Medical Registrar, Department of Psychological Medicine, King Edward VII
Memorial Hospital,

Bombay,

12, India

P. V. Kane, M.SC.,Research Officer, Department of Statistics, Reserve Bank of India, Bombay

S. Ravindranath,
M.SC.,Clinical Statistician, Epilepsy Research Centre, King Edward VII Memorial Hospital,
Bombay,

12, India

(Received 7 July

1972