Electroconvulsive Therapy in Medication-Nonresponsive Patients With Mixed Mania and Bipolar Depression

Background: The aim of this study was to investigate the effectiveness of electroconvulsive therapy (ECT) in medication-nonresponsive patients with mixed mania and bipolar depression.

Method: Forty-one patients with mixed mania (DSM-IV diagnosis of bipolar I disorder, most recent episode mixed) and 23 patients with bipolar depression (DSM-IV diagnosis of bipolar I disorder, most recent episode depressed) consecutively assigned to ECT treatment were included in this study. Subjects were evaluated using the Montgomery-Asberg Depression Rating Scale (MADRS), the Brief Psychiatric Rating Scale (BPRS), and the Clinical Global Impressions-Severity of Illness scale (CGI-S). Assessments were carried out the day before starting ECT, 48 hours after completion of the third session (T₁), and a week after the last session of ECT (T₂).

Results: Both groups received an equal number of ECT sessions (mean ± SD = 7.2 ± 1.7 vs. 7.3 ± 1.6). In both groups, within-group comparisons showed that there was a significant reduction in CGI-S score (mixed mania, p < .0001 at T₁ and T₂; bipolar depression, p < .01 at T₁, p < .0001 at T₂), MADRS total score (both groups, p < .0001 at T₁ and T₂), BPRS total score (mixed mania, p < .0001 at T₁ and T₂; bipolar depression, p < .001 at T₁, p < .0001 at T₂), and BPRS activation factor score (mixed mania, p < .0001 at T₁ and T₂; bipolar depression, NS at T₁, p < .01 at T₂). Between-group comparisons revealed that patients with mixed mania showed significantly greater decrease in MADRS score (p < .001) and a greater proportion of responders (CGI-S) than patients with bipolar depression at endpoint (56% [N = 23] vs. 26% [N = 6], p = .02). Patients with mixed mania showed a greater reduction in suicidality, as measured by MADRS score, than patients with bipolar depression (p < .02).

Conclusion: In our study, ECT was associated with a substantial reduction in symptomatology, in both patients with mixed mania and those with bipolar depression. However, the mixed mania group exhibited a more rapid and marked response as well as a greater reduction in suicidal ideation. Response to ECT was not influenced by the presence of delusions.