ELECTROCONVULSIVE THERAPY AS A SECOND-LINE TREATMENT FOR BIPOLAR MANIA

Sebastian Kupisiak; Aneta Rostkowska; Malwina Draim; Natalia Pasierb; Barbara Rękas; Michalina Kosowska; Wiktoria Dzierzgowska; Aleksandra Sowa; Kacper Trząsalski

doi:10.31435/ijitss.3(47).2025.3658

Authors

Sebastian Kupisiak Czerniakowski Hospital Ltd., ul. Stępińska 19/25, 00-739 Warszawa, Poland https://orcid.org/0009-0007-9631-2314
Aneta Rostkowska Independent Public Clinical Hospital named after Prof. W. Orłowski, ul. Czerniakowska 231, 00-416 Warszawa, Poland https://orcid.org/0009-0007-1142-2507
Malwina Draim Southern Hospital in Warsaw, ul. Witolda Pileckiego 99, 02-781 Warszawa, Poland https://orcid.org/0009-0003-1935-0449
Natalia Pasierb Military Medical Institute – National Research Institute in Warsaw, ul. Szaserów 128, 04-141 Warszawa, Poland https://orcid.org/0009-0002-9701-1162
Barbara Rękas Military Medical Institute – National Research Institute in Warsaw, ul. Szaserów 128, 04-141 Warszawa, Poland https://orcid.org/0009-0004-4474-7226
Michalina Kosowska Military Medical Institute – National Research Institute in Warsaw, ul. Szaserów 128, 04-141 Warszawa, Poland https://orcid.org/0009-0001-8966-342X
Wiktoria Dzierzgowska Military Medical Institute – National Research Institute in Warsaw, ul. Szaserów 128, 04-141 Warszawa, Poland https://orcid.org/0009-0007-4459-2094
Aleksandra Sowa The Hospital of Our Lady of Perpetual Help in Wołomin, ul. Gdyńska 1/3, 05-200 Wołomin, Poland https://orcid.org/0009-0009-3606-8756
Kacper Trząsalski The Infant Jesus Teaching Hospital, Williama Heerleina Lindleya 4, 02-005 Warszawa, Poland https://orcid.org/0009-0002-8425-6865

DOI:

https://doi.org/10.31435/ijitss.3(47).2025.3658

Keywords:

Electroconvulsive Therapy, Bipolar Disorder, Mania, Treatment-Resistant, Efficacy, Safety

Abstract

Introduction and Objective: Bipolar disorder affects approximately 2-4% of the global population, with acute mania representing a significant clinical challenge. While pharmacological interventions remain first-line treatments, 20-30% of patients experience inadequate response or intolerable side effects. This review evaluates the efficacy, safety, and clinical implementation of electroconvulsive therapy (ECT) as a second-line intervention for treatment-resistant bipolar mania.

Material and Methods: A comprehensive analysis of contemporary literature was conducted, examining controlled trials, meta-analyses, systematic reviews, and clinical guidelines published between 1988 and 2024. The review focused on clinical response rates, comparative efficacy studies, adverse effect profiles, technical parameters, and integration with pharmacotherapy.

Results: Evidence consistently demonstrates high efficacy rates (80-90%) for ECT in treatment-resistant mania, with rapid symptom resolution often occurring within the first week of treatment. Modern ECT techniques have substantially mitigated historical concerns regarding cognitive side effects. Bilateral electrode placement traditionally yields faster response in acute mania, though high-dose right unilateral placement may offer comparable efficacy with reduced cognitive impact. Integration with appropriate pharmacotherapy enhances long-term outcomes. Special populations, including pregnant women, elderly patients, and those with medical comorbidities, may particularly benefit from ECT when properly administered with population-specific modifications.

Conclusions: ECT represents an effective, relatively safe, and rapid-acting intervention for treatment-resistant bipolar mania that should be considered earlier in treatment algorithms rather than as a last resort. Individualized approaches to electrode placement, stimulus dosing, and maintenance strategies optimize outcomes while minimizing adverse effects. Future research directions include parameter optimization, identification of predictive biomarkers, and development of cognitive remediation strategies.

References

Abrams, R. (2002). Electroconvulsive therapy (4th ed.). Oxford University Press.

Anderson, E. L., & Reti, I. M. (2009). ECT in pregnancy: A review of the literature from 1941 to 2007. Psychosomatic Medicine, 71(2), 235-242.

Baldessarini, R. J., Vázquez, G. H., & Tondo, L. (2020). Bipolar depression: A major unsolved challenge. International Journal of Bipolar Disorders, 7(1), 1-18.

Barekatain, M., Jahangard, L., Haghighi, M., & Ranjkesh, F. (2008). Bifrontal versus bitemporal electroconvulsive therapy in severe manic patients. Journal of ECT, 24(3), 199-202.

Bolwig, T. G. (2014). Neuroimaging and electroconvulsive therapy: A review. Journal of ECT, 30(2), 138-42.

Consoli, A., Benmiloud, M., Wachtel, L., Dhossche, D., Cohen, D., & Bonnot, O. (2010). Electroconvulsive therapy in adolescents with the catatonia syndrome: Efficacy and ethics. Journal of ECT, 26(4), 259-65.

Fitzgerald, P. B., Hoy, K. E., Elliot, D., McQueen, S., Wambeek, L. E., & Daskalakis, Z. J. (2018). A pilot study of the comparative efficacy of 100 Hz magnetic seizure therapy and electroconvulsive therapy in persistent depression. Depression and Anxiety, 35(5), 393-401.

Fountoulakis, K. N., Vieta, E., Young, A., Yatham, L., Grunze, H., Blier, P., … & Möller, H. J. (2017). The International College of Neuropsychopharmacology (CINP) treatment guidelines for bipolar disorder in adults (CINP-BD-2017), part 4: Unmet needs in the treatment of bipolar disorder and recommendations for future research. International Journal of Neuropsychopharmacology, 20(2), 180-295.

Goodwin, G. M., Haddad, P. M., Ferrier, I. N., Aronson, J. K., Barnes, T., Cipriani, A., … & Young, A. H. (2016). Evidence-based guidelines for treating bipolar disorder: Revised third edition recommendations from the British Association for Psychopharmacology. Journal of Psychopharmacology, 30(6), 495-553.

Grande, I., Berk, M., Birmaher, B., & Vieta, E. (2016). Bipolar disorder. The Lancet, 387(10027), 1561-1572.

Haskett, R. F., Loo, C. (2010). Adjunctive psychotropic medications during electroconvulsive therapy in the treatment of depression, mania, and schizophrenia. The Journal of ECT, 26(3), 196-201.

Hidalgo-Mazzei, D., Berk, M., Cipriani, A., Cleare, A. J., Di Florio, A., Dietch, D., … & Young, A. H. (2019). Treatment-resistant and multi-therapy-resistant criteria for bipolar depression: Consensus definition. The British Journal of Psychiatry, 214(1), 27-35.

Jelovac, A., Kolshus, E., & McLoughlin, D. M. (2013). Relapse following successful electroconvulsive therapy for major depression: A meta-analysis. Neuropsychopharmacology, 38(12), 2467-2474.

Kaster, T. S., Daskalakis, Z. J., Noda, Y., Knyahnytska, Y., Downar, J., Rajji, T. K., … & Blumberger, D. M. (2018). Efficacy, tolerability, and cognitive effects of deep transcranial magnetic stimulation for late-life depression: A prospective randomized controlled trial. Neuropsychopharmacology, 43(11), 2231-2238.

Kellner, C. H. (2018). ECT technique. In C. H. Kellner (Ed.), Handbook of ECT: A guide to electroconvulsive therapy for practitioners (pp. 81-120). Cambridge University Press.

Kellner, C. H., Greenberg, R. M., Murrough, J. W., Bryson, E. O., Briggs, M. C., & Pasculli, R. M. (2012). ECT in treatment-resistant depression. American Journal of Psychiatry, 169(12), 1238-1244.

Kellner, C. H., Husain, M. M., Knapp, R. G., McCall, W. V., Petrides, G., Rudorfer, M. V., … & CORE/PRIDE Work Group. (2016). Right unilateral ultrabrief pulse ECT in geriatric depression: Phase 1 of the PRIDE study. American Journal of Psychiatry, 173(11), 1101-1109.

Kellner, C. H., Tobias, K. G., & Wiegand, J. (2010). Electrode placement in electroconvulsive therapy (ECT): A review of the literature. The Journal of ECT, 26(3), 175-180.

Leiknes, K. A., Cooke, M. J., Jarosch-von Schweder, L., Harboe, I., & Høie, B. (2015). Electroconvulsive therapy during pregnancy: A systematic review of case studies. Archives of Women’s Mental Health, 18(1), 1-39.

Malhi, G. S., Bassett, D., Boyce, P., Bryant, R., Fitzgerald, P. B., Fritz, K., … & Murray, G. (2015). Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders. Australian & New Zealand Journal of Psychiatry, 49(12), 1087-1206.

Medda, P., Toni, C., Mariani, M. G., De Simone, L., Mauri, M., & Perugi, G. (2015). Electroconvulsive therapy in 197 patients with a severe, drug-resistant bipolar mixed state: Treatment outcome and predictors of response. The Journal of Clinical Psychiatry, 76(9), 1168-73.

Mohan, T. S. P., Tharyan, P., Alexander, J., & Raveendran, N. S. (2009). Effects of stimulus intensity on the efficacy and safety of twice-weekly, bilateral electroconvulsive therapy (ECT) combined with antipsychotics in acute mania: A randomised controlled trial. Bipolar Disorders, 11(2), 126-134.

Mukherjee, S., Sackeim, H. A., & Schnur, D. B. (1994). Electroconvulsive therapy of acute manic episodes: A review of 50 years’ experience. American Journal of Psychiatry, 151(2), 169-76.

Oldewening, K., Lange, R. T., Willan, S., Strangway, C., Kang, N., & Iverson, G. L. (2007). Effects of an education training program on attitudes to electroconvulsive therapy. The Journal of ECT, 23(2), 82-8.

Ottosson, J. O., & Fink, M. (2004). Ethics in electroconvulsive therapy. Brunner-Routledge.

Perugi, G., Medda, P., Toni, C., Mariani, M. G., Socci, C., & Mauri, M. (2017). The role of electroconvulsive therapy (ECT) in bipolar disorder: Effectiveness in 522 patients with bipolar depression, mixed-state, mania and catatonic features. Current Neuropharmacology, 15(3), 359-371.

Rami-Gonzalez, L., Salamero, M., Boget, T., Catalan, R., Ferrer, J., & Bernardo, M. (2003). Pattern of cognitive dysfunction in depressive patients during maintenance electroconvulsive therapy. Psychological Medicine, 33(2), 345-50.

Rasmussen, K. G. (2015). Informed consent for electroconvulsive therapy. In C. H. Kellner (Ed.), Handbook of ECT: A guide to electroconvulsive therapy for practitioners (pp. 19-44). Cambridge University Press.

Sahlem, G. L., Short, E. B., Kerns, S., Snipes, J., DeVries, W., Fox, J. B., … & Sackeim, H. A. (2016). Expanded safety and efficacy data for a new method of performing electroconvulsive therapy: Focal Electrically Administered Seizure Therapy. The Journal of ECT, 32(3), 197-203.

Schoeyen, H. K., Kessler, U., Andreassen, O. A., Auestad, B. H., Bergsholm, P., Malt, U. F., … & Vaaler, A. (2015). Treatment-resistant bipolar depression: A randomized controlled trial of electroconvulsive therapy versus algorithm-based pharmacological treatment. American Journal of Psychiatry, 172(1), 41-51.

Semkovska, M., & McLoughlin, D. M. (2010). Objective cognitive performance associated with electroconvulsive therapy for depression: A systematic review and meta-analysis. Biological Psychiatry, 68(6), 568-77.

Sienaert, P. (2014). Mechanisms of ECT: Reviewing the science and dismissing the myths. Journal of ECT, 30(2), 85-86.

Sienaert, P., Lambrichts, L., Dols, A., & De Fruyt, J. (2013). Evidence-based treatment strategies for treatment-resistant bipolar depression: A systematic review. Bipolar Disorders, 15(1), 61-69.

Sienaert, P., Vansteelandt, K., Demyttenaere, K., & Peuskens, J. (2010). Randomized comparison of ultra-brief bifrontal and unilateral electroconvulsive therapy for major depression: Clinical efficacy. Journal of Affective Disorders, 122(1-2), 60-7.

Sienaert, P., Vansteelandt, K., Demyttenaere, K., & Peuskens, J. (2010). Predictors of patient satisfaction after ultrabrief bifrontal and unilateral electroconvulsive therapies for major depression. Journal of ECT, 26(1), 55-9.

Small, J. G., Klapper, M. H., Kellams, J. J., Miller, M. J., Milstein, V., Sharpley, P. H., & Small, I. F. (1988). Electroconvulsive treatment compared with lithium in the management of manic states. Archives of General Psychiatry, 45(8), 727-32.

Tew, J. D., Mulsant, B. H., Haskett, R. F., Joan, P., Begley, A. E., & Sackeim, H. A. (2007). Relapse during continuation pharmacotherapy after acute response to ECT: A comparison of usual care versus protocolized treatment. Annals of Clinical Psychiatry, 19(1), 1-4.

Tørring, N., Sanghani, S. N., Petrides, G., Kellner, C. H., & Østergaard, S. D. (2017). The mortality rate of electroconvulsive therapy: A systematic review and pooled analysis. Acta Psychiatrica Scandinavica, 135(5), 388-397.

Vaidya, N. A., Mahableshwarkar, A. R., & Shahid, R. (2012). Continuation and maintenance ECT in treatment-resistant bipolar disorder. The Journal of ECT, 19(1), 10-6.

Versiani, M., Cheniaux, E., & Landeira-Fernandez, J. (2011). Efficacy and safety of electroconvulsive therapy in the treatment of bipolar disorder: A systematic review. The Journal of ECT, 27(2), 153-64.

Watts, B. V., Groft, A., Bagian, J. P., & Mills, P. D. (2011). An examination of mortality and other adverse events related to electroconvulsive therapy using a national adverse event report system. The Journal of ECT, 27(2), 105-108.

Yatham, L. N., Kennedy, S. H., Parikh, S. V., Schaffer, A., Bond, D. J., Frey, B. N., … & Berk, M. (2018). Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder. Bipolar Disorders, 20(2), 97-170.

Zielinski, R. J., Roose, S. P., Devanand, D. P., Woodring, S., & Sackeim, H. A. (1993). Cardiovascular complications of ECT in depressed patients with cardiac disease. American Journal of Psychiatry, 150(6), 904-9.