• bipolar
• delirious
• duration
• ect
• electroconvulsive therapy
• mania
• manic
• predictors

Introduction: Manic episodes are associated with high morbidity and mortality and represent severe clinical conditions that need urgent interventions. The first choice treatments are mood-stabilizers and antipsychotics. Electroconvulsive therapy (ECT) is indicated in case of refractory mania and, despite historical and recent evidence of efficacy, is heavily underutilized. ECT has been shown to be particularly useful, with response rates ranging from 75% to over 90%, for severe and delirious mania, often associated with life-threatening physical exhaustion, rapid cycling, and drug resistance,.
Aim of the study: The short-term outcome of a sample of severe and drug resistant manic patients treated with ECT was evaluated in order to explore possible demographic and clinical predictors of non-response.
Method: This naturalistic and observational study was conducted in a cohort of 24 treatment-resistant manic patients who underwent bilateral ECT between January 2006 and December 2021. All patients were evaluated prior and after the ECT course using the Brief Psychiatric Rating Scale (BPRS), the Young Mania Rating Scale (YMRS) and the Clinical Global Impression scale (CGI). All patients showed a particularly severe manic symptomatology nonresponsive to multiple treatment trials with a combination of mood stabilizers, antipsychotics and benzodiazepines.
Results: Overall, 75% of the sample responded to ECT. Chronicity of the episode, intended as a duration > 6 months and, generally, its duration emerged as significantly different between responder and non-responders and acted as predictors of non-response (p<0.10). Responders showed higher rates of delirious mania (p<0.10), which was characterized by shorter episodes with higher severity on YMRS scoring, and it resulted to be associated with response to ECT (OR 10.65, p<0.10).
Conclusions: Overall, 75% of our severe drug resistant manic patients responded to ECT. In our sample, the duration of the manic episode and the chronicity of manic symptoms (> 6 months) are associated with non-response to ECT. This result is consistent with previous observation on depression and mixed states. The high response rate of the entire sample and the high rate of remission of delirious mania are in line with the results of naturalistic studies on real-world practice. Our results seems to indicate the use of ECT for this clinical picture in the early stages of treatment, and not as “last resort”. Further controlled studies in larger samples are necessary.