Electroconvulsive Therapy Linked to Manic Episode Response

Most patients with mania responded to electroconvulsive therapy (ECT), a Swedish population-based study found.

Among 571 individuals who were in a manic episode, 482 (84.4%) responded to treatment with ECT, reported Katarzyna Popiolek, MD, of Örebro University Hospital in Sweden, and colleagues.

And 28% of these patients were able to achieve remission of mania, the group wrote in JAMA Network Open.

“These findings suggest that ECT may be a highly effective option for treating mania, which is in line with the literature reporting response rates of 56% to 100%,” Popiolek’s group noted.

Having more severe illness was a top predictive factor of which patients would respond to this particular type of therapy.

More specifically, the most extremely ill patients had a nearly eight-fold greater chance of responding to ECT compared with those with either mild or moderate illness:

• Markedly ill (adjusted OR 2.93, 95% CI 1.23-7.00)
• Severely ill (aOR 2.60, 95% CI 1.06-6.34)
• Most extremely ill (aOR 7.94, 95% CI 2.16-29.21)

This equated to 83%, 84%, and 92% of markedly ill, severely ill, and most extremely ill patients having a clinical response to ECT, respectively. Illness severity was graded according to Clinical Global Impression Improvement scale (CGI-I) score.

Additionally, patients who underwent more ECT treatments in an index series were significantly more likely to have a clinical response. The highest chances of response were among patients who received more than nine treatments.

On the other hand, Popiolek’s group found clinical factors that were predictive of a patient not responding to ECT included comorbid anxiety (aOR 0.48, 95% CI 0.25-0.90) and comorbid obsessive compulsive disorder (aOR 0.17, 95% CI 0.06-0.56).

Factors that weren’t associated with a clinical response to ECT were age of mania onset, as well as psychopharmacotherapy before index admission, including lithium, lamotrigine, a first or second generation antipsychotic, valproate, benzodiazepine, antidepressant, anxiolytic, or a central stimulant.

“It is worth highlighting that 63% of patients in our study were treated with 1 or more antimanic agents before admission, suggesting that these treatments may not have been sufficient in reducing symptoms of mania,” the group noted.

This nationwide Swedish study included patients who were admitted to any hospital in the country and subsequently treated with ECT for mania between 2012 and 2019. Mania was diagnosed according to ICD-10 codes for a manic episode without psychotic symptoms, manic episode with psychotic symptoms, bipolar disorder with current manic episode without psychotic features, bipolar disorder with a current manic episode with psychotic features, or bipolar disorder with current mixed episode.

A total of 63% of the cohort was female, and the median age was 46. Most of the cohort had mania with psychotic symptoms. About a quarter were voluntarily admitted to the hospital, while 60% were involuntarily committed. About 45% had been exposed to prior ECT.

The majority of the patients received ECT three times per week, which is the “traditional frequency” in Sweden, the researchers pointed out. The median number of treatments was six.