ECT-Induced Mania in Bipolar Disorder: Case Report From Belgium

Out on PubMed, from authors in 

Electroconvulsive Therapy-Induced Mania in Bipolar Disorder: A Case Report.

Van Eenoo S, Bollen O, Janssens S.Cureus. 2024 Dec 7;16(12):e75255. doi: 10.7759/cureus.75255. eCollection 2024 Dec.PMID: 39764330

The abstract is copied below:

Electroconvulsive therapy (ECT) is widely recognized as a safe and effective intervention for treating severe affective episodes in patients with bipolar disorder. However, it can sometimes precipitate unexpected manic phases in patients treated for a depressive episode, a phenomenon known as ECT-induced mania. While this occurrence is recognized, it remains poorly understood and minimally addressed in the literature. This article presents a case study of a 56-year-old man diagnosed with bipolar I disorder with rapid cycling and late-onset features who received ECT to treat a severe depressive episode with psychotic and catatonic features but developed a manic episode with psychotic elements shortly after ECT initiation. The onset of mania coincided with the discontinuation of valproate, which may have further increased the likelihood of a mood switch. A literature review suggests four main clinical strategies for managing ECT-induced mania: (1) cessation of ECT, (2) cessation of ECT and initiation of pharmacotherapy, (3) continuation of ECT, and (4) continuation of ECT alongside the addition of lithium as a mood stabilizer. However, the limited and primarily case-based nature of existing research makes it challenging to establish universally applicable treatment guidelines. In the described case, treatment was modified by temporarily suspending ECT and introducing lithium, which helped stabilize the patient's manic symptoms. ECT was later resumed with lithium maintenance, achieving improved mood stability. This case highlights the complexities associated with ECT in bipolar disorder, particularly the potential for manic induction, especially when mood stabilizers are withdrawn. It underscores the need for rigorous patient assessment and monitoring, as well as further research to clarify optimal management strategies and preventive measures for ECT-induced mania.

Keywords: acute mania; adverse effects ect; adverse effects of ect; bipolar disorders; brain and bipolar disorder; ect rare complication; electroconvulsive therapy (ect); lithium; treatment of psychiatric illness and ect.

The report is here.

And from the text:

Here is a case report that reminds us of the rare occurrence of a hypo- or manic  ECT-induced switch. It reminds us that ECT is a mood stabilizer (treats both depression and mania) and an excellent antidepressant (the best test for which is the ability to precipitate mania).

I would like to praise these authors for their succinct description of the technical details of the ECT:

A bitemporal electrode placement was selected, and anesthesia was

administered with etomidate and succinylcholine. The patient was then treated with a 30% charge (151.2mC) on the LOW 0.5 program on the Thymatron System IV.

While I am not condoning all the clinical decisions that followed, my point is that many ECT case reports do not have even this level of detail.

While a switch into frank mania is a serious problem, a switch into a few days of self-resolving hypomania after a long episode of profound psychotic and suicidal depression is usually considered a clinical success.