A 48-year-old woman with severe treatment-resistant major depressive disorder is being considered for ECT. Regarding ECT electrode placement, which statement is TRUE about right unilateral (RUL) vs bilateral (BL) ECT?

• A Bilateral ECT has fewer cognitive side effects than right unilateral ECT
• B Left unilateral ECT is standard; right unilateral is experimental
• C Bilateral ECT is contraindicated in depression with psychosis
• D Right unilateral ECT at 6× seizure threshold equals bilateral ECT in efficacy with less cognitive impairment ✓

Explanation

ECT electrode placement determines both efficacy and cognitive side effects. Bilateral (bitemporal or bifrontal) ECT has slightly faster antidepressant response but more cognitive adverse effects (memory impairment, confusion). Right unilateral (RUL) ECT at high dose (≥6× seizure threshold) achieves equivalent efficacy to bilateral ECT with significantly less cognitive impairment — this is now standard practice for most patients. Bilateral ECT at low-moderate stimulus dose (near threshold) produces cognitive impairment without added efficacy benefit. Acute mania, catatonia, and psychotic depression are among the strongest indications for ECT.

Reference: Kaplan & Sadock's Synopsis of Psychiatry, 11th ed.

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