Electroconvulsive Therapy for Bipolar Disorder: Evidence Supporting What Clinicians Have Long Known

Abstract

T he effectiveness of electroconvulsive therapy (ECT) as an acute antidepressant is well known; less commonly known is the effectiveness of ECT as a mood stabilizer, that is, as an antimanic treatment, and by extension, an antimixed state treatment. In this issue of the Journal, Medda and colleagues' 1 report of the high effectiveness of ECT in a cohort of nearly 200 bipolar patients with mixed affective states adds important evidence to this knowledge base. In this commentary, we review the evidence for the effectiveness of ECT in all phases of bipolar disorder.There is no reason to suspect that ECT would be any less effective for bipolar depression than for unipolar depression, yet this remains a commonly held belief. Similarly, many practitioners seem to think that there is only meager evidence for ECT's effectiveness in bipolar depression, but this is untrue. There is a long history of clinical use of ECT for bipolar depression and a systematic evidence base that is catching up with this experience.In a study of the efficacy of ECT in a cohort of 220 unipolar (n = 170) and bipolar (n = 50) depressed patients, Bailine et al 2 found no significant difference in remission rates between the 2 groups when remission was defined as a score of less than or equal to 10 on the 24-item Hamilton Depression Rating Scale (HDRS 24 ). Similarly, recent studies by Dierckx et al 3 and Narayanaswamy et al 4 comparing ECT response and remission rates among bipolar and unipolar depressed patients found no significant difference in the efficacy of ECT. Some studies have also shown that bipolar depressed patients require fewer treatments to achieve "responder" or "remitter" status. In the study of Sienaert et al, 5 bipolar depressed patients (n = 13) required approximately 7-8 treatments to achieve response or remission status, whereas unipolar depressed patients (n = 51) required, on average, 9-11 treatments to achieve response or remission. Likewise, in a reanalysis of data by Daly et al, 6 bipolar patients (n = 66) showed a 54.9% reduction (SD = 31.9%) in HDRS score compared with a 43.9% reduction (SD = 29.8%) among unipolar patients (n = 162) after 6 ECT treatments. Medda et al7 reviewed the efficacy of ECT in all 3 depressive subtypes; response rates were high for all (unipolar, 88.2%, n = 17; bipolar I, 69.6%, n = 67; and bipolar II, 73.1%, n = 46). However, bipolar I depressed patients exhibited higher residual manic and psychotic symptomatology, as measured by the Young Mania Rating Scale (YMRS) and Brief Psychiatric Rating Scale (BPRS).Electroconvulsive therapy has long been used as a "rescue" treatment for refractory mania. In contemporary psychiatric practice, most, even severely, manic patients eventually respond to pharmacotherapy-usually a combination of mood stabilizers and tranquilizers, often at high doses. For those who do not, ECT is an important and usually quickly effective alternative treatment.In a review of the use of ECT in mania over a period of 50 years, Mukherjee et al 8 concluded that 80% of 589 manic ...

Management of obsessive-compulsive disorder comorbid with bipolar disorder

“…[124125] There are reported cases of BD-OCD[126] and schizoaffective disorder-OCD[127] improved with ECT. Hence, ECT may be of some use in acute manic/depressed bipolar patients with comorbid OCD.…”

ECT beyond unipolar major depression: systematic review and meta‐analysis of electroconvulsive therapy in bipolar depression

“…However, using ECT to treat other phases of bipolar disorder, such as mania and mixed states, is often overlooked . Some suggest that the underuse of ECT in these settings is due to the less commonly known effectiveness of ECT as a mood stabilizer (in addition to its antidepressant properties) .…”

Electroconvulsive therapy for manic state with mixed and psychotic features in a teenager with bipolar disorder and comorbid episodic obsessive–compulsive disorder: a case report

“…There is strong evidence supporting the efficacy and safety of ECT as an acute antidepressant in adolescent psychiatry; less commonly known is the effectiveness of ECT as a mood stabilizer and anti-manic treatment, and thereby also as possible treatment in bipolar states with mixed features [ 10 , 11 ]. ECT seemingly continues to be at the very bottom of pediatric treatment algorithms [ 14 , 22 ].…”

“…Electroconvulsive therapy (ECT) is documented to be a safe and efficacious intervention in manic, depressed, and mixed states of BD and in a few cases of OCD in adults [ 10 , 11 ]. ECT is rarely used in adolescents, usually only for indications that involve severe depression or life-threatening conditions, for example catatonia [ 12 – 15 ].…”