Some of the earliest case reports of the efficacy of convulsive therapy (both chemical and electrical) concerned patients with mania. In reviewing the early literature on ECT in mania, Mukherjee et al (1994) noted that the proportion of patients showing remission or marked clinical improvement varied between 63% and 84%.

Electroconvulsive therapy is no longer regularly considered in the UK for the treatment of mania. There is no mention of ECT for management of acute mania in the NICE guideline on bipolar disorder (2006). This was in spite of the acknowledgement by NICE that ECT is an effective treatment for mania (National Institute for Clinical Excellence, 2003). In contrast, both the American Psychiatric Association and World Federation of Societies of Biological Psychiatry treatment guidelines recommend the use of ECT in the treatment of acute manic episodes which are resistant to treatment with antipsychotic and mood-stabilising medication (American Psychiatric Association, 2002; Grunze et al, 2010).

Efficacy of ECT in acute mania

There have been no new randomised controlled studies of ECT in acute manic episodes since the previous edition of The ECT Handbook.

Retrospective studies

McCabe (1976) compared patients with mania treated with ECT against an untreated matched control group from a period when ECT was unavailable. The ECT-treated group had a better outcome and shorter hospital stay. These two groups were then compared with a matched group treated with chlorpromazine (McCabe & Norris, 1977). Of the 28 patients treated with chlorpromazine, 18 responded. The 10 patients who did not respond satisfactorily to chlorpromazine, recovered with ECT treatment. This is in comparison to the ECT-treated group, in which all 28 patients responded. Thomas & Reddy (1982) found ECT, chlorpromazine and lithium to be equally effective. Black et al (1987) found that a significantly greater proportion of ECT-treated patients improved markedly than lithium-treated patients. Three other studies, with no comparison groups, found marked clinical improvement or remission in 56–78% of patients (Alexander et al, 1988; Stromgren, 1988; Mukherjee & Debsikdar, 1992).

Prospective studies

There have been three prospective studies of the efficacy of ECT in mania. Small et al (1988) randomised 34 patients admitted to hospital with mania to ECT or lithium carbonate. Unilateral ECT was initially prescribed but with the option of switching to bilateral ECT. The details of stimulus dosing were not provided.