New Review of ECT in Mania

Out on PubMed, from researchers in Australia and the USA, is this review:

Electroconvulsive Therapy in Mania: A Review of 80 Years of Clinical Experience.

Elias A, Thomas N, Sackeim HA.Am J Psychiatry. 2020 Nov 10:appiajp202020030238. doi: 10.1176/appi.ajp.2020.20030238. Online ahead of print.PMID: 33167675

The abstract is copied below:

Resistance to pharmacological agents is commonly encountered in the treatment of acute episodes of mania. In contemporary practice guidelines, electroconvulsive therapy (ECT), once a widely used standalone intervention for mania, is no longer considered a first-line treatment. Stigma, logistics, and ethical factors constrain ECT administration in this condition and lead to its underutilization. However, the past three decades have produced promising research regarding the use of ECT in mania. Randomized controlled trials, albeit in limited numbers, the adoption of ultrabrief ECT, examination of the safety and efficacy of combining ECT with pharmacological agents, including lithium, and use of ECT as a maintenance strategy have enhanced our understanding of how and when to utilize this intervention in mania. In this comprehensive review, the authors summarize the evidence regarding the efficacy and safety of ECT in mania, including related syndromes, such as delirious mania and mixed affective states. The impact of technical parameters, particularly the choice of treatment frequency, electrode placements, and pulse width, are discussed in the light of recent evidence.

Keywords: Anticonvulsants; Bipolar Disorder; Electroconvulsive Therapy; Mania; Mood Disorders.

And from the text:

In comparison with ECT in major depressive episodes, its application in mania has been far less documented. Many practitioners are unaccustomed to the use of ECT in mania, and consequently it is underutilized. An important difference in the pharmacotherapy between major depression and mania is the long latency for remission in depression, while manic symptoms respond quite rapidly. This difference may explain the reduced need for ECT in mania. Prospective studies contrasting the efficacy of ultrabrief ECT in acute mania with a pharmacotherapy comparator group can expand
the horizons. Furthermore, predictors of response to ECT in mania have received little attention. Increased educational campaigns among both professionals and the lay public are important to enhance awareness of the beneficial, and at times, the life-saving role of ECT in mania. The combined use of ECT and mood stabilizers, including lithium, requires further clarification. Guidelines should reconsider their position regarding the role of ECT in mania based on the best available evidence, as well as the interests of this patient community.

This is a comprehensive and scholarly review that is a welcome addition to the literature.  A particularly interesting suggestion is that ECT may be even more "antimanic" than antidepressant.

The idea that mania is exquisitely sensitive to ECT, leads the authors to the promotion of right unilateral ultrabrief pulse ECT as the ECT technique of choice.  This is a somewhat idiosyncratic view, based on the legacy of the Columbia University studies, led by Dr. Sackeim. The authors do not distinguish between safety and tolerability, and may be prematurely promoting less effective forms of ECT, often for urgently ill patients. 

The above bias notwithstanding, this review deserves a careful read (about 20 minutes.)