ORIGINAL STUDY
Effectiveness and Cognitive Changes With Ultrabrief Right
Unilateral and Other Forms of Electroconvulsive Therapy in
the Treatment of Mania
Vincent Khung Hoon Wong, MBChB,* Phern Chern Tor, MBBS, DFD(CAW), MMed (Psychiatry), FAMS,*
Donel M. Martin, MClinNeuro, PhD,†‡ Yee Ming Mok, MB BCh BAO, DIP, MMed, FAMS,*
and Colleen Loo, MBBS, FRANZCP, MD†‡
Objective: Electroconvulsive therapy (ECT) is an effective treatment in
mania. However, there is little evidence regarding the use of ultrabrief right
unilateral (RUL-UB) ECT in treatment of acute manic episodes. The aim of
this study was to report on the effectiveness and cognitive profile of ECT in
bipolar mania, including a sample who received RUL-UB ECT.
Methods: This naturalistic study retrospectively collected data in 33 patients
who received ECT with concurrent antipsychotics for mania between
October 1, 2014, and July 30, 2016. Electroconvulsive therapy was given
using RUL-UB, brief-pulse right unilateral, or brief-pulse bitemporal ap-
proaches, dosed according to the patient's seizure threshold. The Brief Psy-
chiatric Rating Scale (BPRS), Young Mania Rating Scale (YMRS) score,
and the Montreal Cognitive Assessment (MoCA) were administered to pa-
tients before and after the ECT course.
Results: For the whole sample, there was a significant improvement in
BPRS (total score and manic subscale), YMRS, and MoCA total scores
across the ECT treatment course. The overall BPRS response rate was
84%, and mean scores decreased from 42.1 (SD, 12.0) to 26.0 (SD, 4.0).
The 13 patients who received RUL-UB ECT also showed significant im-
provement in BPRS, YMRS, and MoCA scores over the treatment course.
Conclusions: Electroconvulsive therapy in general and also specifically
RUL-UB ECT were effective in treating mania and also led to global
cognitive improvement.
Key Words: bipolar affective disorder, mania, ultrabrief ECT
(J ECT 2019;35: 40–43)
B ipolar disorder is a disabling psychiatric disorder with a life-
time prevalence of 4.4%. From the Global Burden of Disease
Study, there were 48.8 million cases of bipolar disorder globally in
2013,1 an almost 50% increase in prevalence compared with the
year 1993. It accounted for 9.9 million disability-adjusted life-
years (DALYs) in 2013, 0.4% of total DALYs.1
For the acute manic phase of bipolar disorder, electroconvul-
sive therapy (ECT) has been proven to be an effective treatment.2–4
Electroconvulsive therapy has been shown to be equivalent or su-
perior to pharmacotherapy, including lithium,5 haloperidol,6 and
chlorpromazine.7 It was also demonstrated to reduce the length of in-
patient stay8 and is a valid treatment option for treatment-resistant
mania.9 With growing supporting evidence, ECT has been widely
From the *General Psychiatry, Institute of Mental Health, Singapore; †Black
Dog Institute, Sydney; and ‡School of Psychiatry, University of New South
Wales, Sydney, Australia.
Received for publication January 9, 2018; accepted May 13, 2018.
Reprints: Phern Chern Tor, MBBS, DFD(CAW), MMed (Psychiatry), FAMS,
General Psychiatry, Institute of Mental Health, 10 Buangkok View,
Buangkok Green Medical Park, 539747 Singapore
(e‐mail: phern_chern_tor@imh.com.sg).
The authors have no conflicts of interest or financial disclosures to report.
Supplemental digital contents are available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions
of this article on the journal’s Web site (www.ectjournal.com).
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/YCT.0000000000000519
40 www.ectjournal.com
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
implemented in treating mania across the globe. In Asia, it is the
third most common indication for receiving ECT (14%), after
schizophrenia and major depressive disorder.10
However, cognitive adverse effects have been a major factor
limiting the use of ECT.11 The main adverse effects are retrograde
and anterograde amnesia. Ultrabrief right unilateral (RUL-UB)
ECT is a relatively new form of ECT that has a shorter pulse
width, resulting in fewer cognitive adverse effects.12–15 Although
RUL-UB ECT has been extensively studied in depression, there is
a comparative lack of evidence in the literature regarding the use
of RUL-UB ECT in the treatment of acute manic episodes. Sev-
eral recent case series16–18 in patients with acute manic episodes
have demonstrated that RUL-UB ECT may be effective in mania
with minimal cognitive adverse effects. The emerging evidence
suggests that RUL-UB ECT may be a safe and effective alternative
to pharmacological interventions for patients in an acute mania ep-
isode. However, these studies did not use standardized psychiatric
symptom or cognitive rating scales, limiting interpretation of out-
comes from treatment in this population.
Hence, we examined the effect of RUL-UB ECT in the treat-
ment of a cohort of manic patients, among a larger sample who
also received other forms of ECT. We conducted a retrospective
naturalistic study by analyzing an existing clinical database of pa-
tients receiving ECT for treatment of mania at the Institute of Men-
tal Health (IMH), Singapore's only tertiary psychiatric hospital. The
Neurostimulation Service in IMH is in charge of providing ECT
services. It had undergone several transitions, adapting different
ECT modalities one at a time, starting from an age-based dosing
method with bitemporal electrode placement19 and brief pulse to
an individualized seizure threshold titration–based approach,20 in-
troduction of RUL electrode placement, and ultrabrief pulse width.21
The aim of this article is to report the effectiveness and cognitive
profile of RUL-UB ECT and these other ECT modalities for pa-
tients treated for bipolar mania in a clinical setting.
METHODS
Patients, ECT, and Study Design
This study was based on an archival retrospective review of
ECT cases done at the Neurostimulation Service of the IMH.
We audited records of all patients who received and completed
ECT in IMH between October 1, 2014, and July 30, 2016. Patient
inclusion criteria were that patients received ECT for a manic ep-
isode of bipolar affective disorder (manic type) and that the same
type of ECT was used throughout the treatment course. Patients
were diagnosed and assessed by the ward psychiatrist based on
the fourth and fifth editions of the Diagnostic and Statistical Manual
of Mental Disorders or the International Classification of Diseases,
10th Revision criteria. Bipolar and related disorders due to another
medical condition and substance/medication-induced bipolar and
Journal of ECT • Volume 35, Number 1, March 2019
Journal of ECT • Volume 35, Number 1, March 2019
related disorders were excluded. All patients were also on concomitant
antipsychotic medication, and most were also on mood stabilizers.
Across the study duration, the Neurostimulation Department
of IMH changed ECT treatment protocols for mania several times,
although only 1 type of ECT was specified in the clinical protocol
at any given time, in the following order: bitemporal ECT with
0.5-millisecond pulse width and age-based dosing (% machine
energy = age [in years] − 10) (BT-B [AB]), bitemporal ECT with
0.5-millisecond pulse width, given at 1.5 seizure threshold
(BT-B), right unilateral ECTwith a brief pulse width (0.5 millisec-
ond) given at 5 seizure threshold (RUL-B), and right unilateral
ECTwith an ultrabrief pulse width (0.3 millisecond) at 6 seizure
threshold (RUL-UB). All ECT procedures were conducted with a
Thymatron System IV (Somatics, LLC); for brief pulse, the 2X
DGX program was used. Electroconvulsive therapy doses were
further increased as required over the treatment course, based on
patient response or decrease in electroencephalogram quality. Dura-
tion of the treatment course was according to the clinical judgment
of the ward psychiatrist, who had access to rating scale outcomes.
Each type of ECT was used as the default type of ECT treatment
in the clinical service for approximately 4 months.21
Data on patient characteristics, ECT treatment, efficacy, and
cognitive ratings were extracted from electronic and physical pa-
tient records completed by medical officers and case managers.
Outcome Measures
Psychiatric symptoms and cognitive outcomes for patients in
the study were assessed using specific rating scales performed at
baseline and after completing their course of ECT. Electroconvul-
sive therapy effectiveness was assessed by the Brief Psychiatric
Rating Scale (BPRS)22 and Young Mania Rating Scale (YMRS)
score.23 Brief Psychiatric Rating Scale response was defined as
a 50% or greater reduction in baseline total score.24 Patients were
considered to achieve remission on YMRS when they scored 12
or less.25 The Montreal Cognitive Assessment (MoCA)26 was ad-
ministered to assess cognitive outcomes.
Brief Psychiatric Rating Scale ratings were performed by the
ECT medical officers. They received rating training using stan-
dardized training video under the supervision of P.C.T., head of
IMH Neurostimulation service. Using 3 sets of patient videos, the
intraclass correlation between the 4 BPRS raters was 0.77. The Young
Mania Rating Scale was performed by case managers of the refer-
ring ward multidisciplinary team with the same case manager doing
pre/post-ECT assessments for each patient. The MoCA assessment
was done by ECT nurses who underwent training by P.C.T. and a
registered neuropsychologist (D.M.). The MoCA assessments
were completed in local languages.27 The main reason for missing
data was logistical, for example, discharge of patients before rat-
ing scale outcomes were completed.
This project was approved by the local institutional research
ethics board.
Data Analysis
The analysis was restricted to patients who had complete
pre/post-ECT BPRS data. Eight patients (19.5%) were removed be-
cause of incomplete BPRS scores, leaving a total of 33 patients for
analysis. Before analysis, to determine that there were no statisti-
cally significant differences between the patient groups with and
without complete pre/post-ECT BPRS data, the demographic data
of both cohorts were compared via analysis of variance. Details
are shown in the Appendix, Supplementary Table 1 (Supplemen-
tal Digital Content 1, http://links.lww.com/JECT/A75).
The data collected were categorized into 4 groups by ECT
types, which were BT-B (AB) ECT, RUL-B ECT, BT-B ECT, and
© 2018 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
RUL-UB ECT in the Treatment of Mania
RUL-UB ECT. Paired-sample t tests examined changes from
before to after ECT for BPRS, BPRS Mania subscale (tension,
uncooperativeness, excitement, mannerisms, and posturing),28
YMRS, and MoCA scores, for the whole sample and for the RUL-UB
subgroup separately. Pearson correlations were used to investigate
for correlation between change in BPRS scores and changes in
MOCA scores for the whole sample and for the RUL-UB subgroup.
Data from other ECT groups were not formally analyzed because
of small numbers of patients in these groups. Significance level
was set at P < 0.05.
RESULTS
Patient Characteristics
There were 48 patients who received ECT for mania; 7 patients
(14.5%) were excluded as they received more than 1 type of ECT.
Only 1 of these 7 patients started with RUL-UB ECT, which was
eventually switched to RUL-B ECT.
Details of patient demographics and ECT delivery are shown
in Table 1. There were no significant differences between the groups on
clinical and demographic variables shown in Supplementary Table 1
(Supplemental Digital Content 1, http://links.lww.com/JECT/A75).
Effectiveness
Electroconvulsive therapy was an effective treatment for manic
episodes in bipolar affective disorders with an overall BPRS response
rate of 84%. There were statistically significant improvements in
BPRS scores (t28 = 7.68, P < 0.01), BPRS Mania subscale
(t30 = 5.22, P < 0.01), and YMRS scores (t16 = 7.73, P < 0.01)
for the whole cohort and also within the RUL-UB ECT group
(BPRS: [t12 = 5.57, P < 0.001], BPRS Mania subscale [t10 = 2.61,
P = 0.03], YMRS: [t12 = 6.70, P < 0.01]) (Table 2).
Cognitive Outcomes
For the sample as a whole, MoCA scores improved over the
course of ECT (t22 = 2.8, P < 0.01). The RUL-UB ECT group also
showed a significant increase in MoCA scores over the course of
ECT (t9 = 3.2, P < 0.01). There was no correlation between change
in BPRS scores and changes in MOCA scores in the whole sample
(r = 0.48, P = 0.81, n = 26) and RUL-UB ECT (r = 0.41, P = 0.24,
n = 10). Detailed breakdown of pre and post MoCA domains are
shown in the Appendix, Supplementary Table 2 (Supplemental
Digital Content 1, http://links.lww.com/JECT/A75).
DISCUSSION
This study showed that ECT, given in addition to concomi-
tant medication, was an effective and rapid treatment for acute
manic episodes, resulting in both improved psychiatric symptoms
and improved cognitive outcomes.
A recent meta-analysis showed a small efficacy advantage of
brief pulse-width RUL-B ECT compared with RUL-UB ECT in
the treatment of depression,21 and an analysis of speed of response
found that improvement may be slightly slower in RUL-UB ECT.29
However, the effectiveness of RUL-UB ECT in the treatment of
mania has been minimally reported. Although preliminary, the re-
sults of the present study are promising and encourage further ex-
amination of RUL-UB ECT for the treatment of mania.
Ultrabrief right unilateral ECT was expected to yield relatively
good cognitive outcomes, based on prior findings in depression
studies.14 There are limited data on cognitive outcomes following
ECT in the treatment of mania. One recent study suggested that
there was no permanent memory impairment in patients with bipolar
I disorder after receiving bifrontal ECT treatment.30 The nature and
www.ectjournal.com 41
Wong et al Journal of ECT • Volume 35, Number 1, March 2019

TABLE 1. Patient Characteristics and ECT Treatment Parameters

Overall BT-B (AB) RUL-B RUL-UB BT-B

(n = 33) (n = 4) (n = 7) (n = 13) (n = 9)
Age, mean (SD), y 46.5 (16.7) 62.5 (22.8) 51.0 (15.5) 40.3 (12.6) 44.0 (18.0)
Sex (male), n (%) 19 (57.6) 3 (75) 2 (28.6) 10 (76.9) 4 (44.4)
Duration of illness, mean (SD), mo 138.0 (110.6) 186.7 (161.0) 78.6 (60.8) 157.5 (109.0) 134.6 (117.1)
CPZ equivalent, mean (SD), mg 655.3 (286.0) 498.3 (279.4) 538.1 (245.3) 680.8 (294.8) 779.6 (282.1)
No. ECTs, mean (SD) 8.09 (2.8) 7.0 (4.2) 8.6 (1.8) 7.38 (2.1) 9.8 (3.5)
Initial ECT seizure threshold, mean (SD), mC (n = 27) (n = 0) (n = 6) (n = 13) (n = 8)
54.9 (46.5) NA* 44.5 (19.0) 39.2 (28.8) 88.2 (67.3)
Initial ECT dosage, mean (SD), mC (n = 29) NA* (n = 7) (n = 13) (n = 9)
202.5 (135.3) 234.0 (64.6) 236.5 (172.0) 128.8 (87.7)
Final ECT dosage, mean (SD), mC (n = 30) (n = 1) (n = 7) (n = 13) (n = 9)
286.8 (153.6) 151.2 288.0 (84.7) 235.7 (184.7) 229.6 (141.1)
Propofol dosage, mean (SD), mg (n = 27) NA* (n = 6) (n = 13) (n = 8)
67.0 (15.6) 63.3 (18.6) 72.3 (16.4) 61.3 (9.9)
Suxamethonium dosage, mean (SD), mg (n = 27) NA* (n = 6) (n = 13) (n = 8)
32.6 (9.3) 37.5 (14.4) 31.9 (7.9) 30.0 (6.5)
*Data were unavailable.
BT-B indicates bitemporal seizure threshold–based dosing; BT-B (AB), bitemporal age-based dosing; CPZ, chlorpromazine; RUL-B, right unilateral sei-
zure threshold–based dosing; RUL-UB, ultrabrief right unilateral seizure threshold–based dosing.

extent of cognitive impairment have been found to be different
between depressive and manic patients, particularly on complex
cognitive tasks subserved by neural networks including the
orbitofrontal/ventromedial prefrontal cortex.31,32 In this study,
the sample as a whole and the RUL-UB ECT group had statisti-
cally significant increases in post-ECT MoCA scores, indicating
improvement in global cognitive functioning. These findings need
to be confirmed with more comprehensive cognitive assessment
instruments and in larger numbers of patients.
This study is limited in that data were extracted retrospec-
tively from clinical files, although outcomes were measured pro-
spectively as part of the routine clinical service, using some of
the structured instruments recommended in the Clinical Alliance
and Research in ECT initiative.33 Assessment for autobiographical

TABLE 2. BPRS, YMRS, and MoCA Scores Before and After ECT

Overall BT-B (AB) RUL-B RUL-UB BT-B

(n = 33) (n = 4) (n = 7) (n = 13) (n = 9)
Baseline BPRS, mean (SD) 42.1 (12.0) 51.8 (14.0) 43.9 (11.0) 43.5 (11.8) 34.3 (9.0)
Post-ECT BPRS, mean (SD) 26.0 (4.0)* 26.8 (4.1) 28.7 (5.4) 25.7 (2.2)* 23.9 (3.9)
BPRS response (%) 28 (84%) 4 (100.0%) 5 (71.4%) 12 (92.3%) 7 (77.8%)
Baseline BPRS Mania subscale, mean (SD) (n = 31) (n = 4) (n = 7) (n = 11) (n = 9)
5.4 (2.2) 7.0 (4.2) 5.4 (1.3) 5.3 (2.3) 4.8 (1.6)
Post BPRS Mania subscale, mean (SD) (n = 32) (n = 4) (n = 7) (n = 12) (n = 9)
3.2 (0.8)* 3.0 (0.0) 3.71 (1.5) 3.08 (0.3)* 3.1 (0.3)
Baseline YMRS (n = 17), mean (SD) (n = 18) (n = 1) (n = 2) (n = 13) (n = 2)
28.8 (13.5) 41.0 22.0 (0.0) 28.3 (15.3) 33.0 (4.2)
Post-ECT YMRS (n = 17), mean (SD) (n = 18) (n = 1) (n = 2) (n = 13) (n = 2)
1.9 (5.3)* 2.0 12.5 (13.4) 0.5 (1.9)* 0.5 (0.7)
YMRS remission (n = 17), n (%) (n = 18) (n = 1) (n = 2) (n = 13) (n = 2)
17 (94%) 1 (100%) 1 (50.0%) 13 (100%) 2 (100.0%)
Baseline MoCA (n = 26), mean (SD) (n = 29) (n = 3) (n = 6) (n = 12) (n = 8)
19.5 (8.1) 14.3 (6.7) 22.3 (6.5) 21.7 (7.3) 15.6 (10.3)
Post-ECT MoCA (n = 25), mean (SD) (n = 29) (n = 4) (n = 6) (n = 10) (n = 9)
22.4 (8.1)* 11.3 (6.8) 21.2 (7.2) 26.3 (2.4)* 22.7 (9.1)
*Post-ECT scores that were statistically significantly different from pre-ECT scores in the overall sample and RUL-UB sample.
BT-B indicates bitemporal seizure threshold–based dosing; BT-B (AB), bitemporal age-based dosing; RUL-B, right unilateral seizure threshold–based
dosing; RUL-UB, ultrabrief right unilateral seizure threshold–based dosing.

42 www.ectjournal.com © 2018 Wolters Kluwer Health, Inc. All rights reserved.

Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Journal of ECT • Volume 35, Number 1, March 2019
memory, an important cognitive adverse effect, is recommended
in the Clinical Alliance and Research in ECT framework but
was not assessed because of the difficulty of assessing this within
a busy clinical service. Concurrent medications during ECT were
based on clinician judgment and not controlled between ECT
groups. Nevertheless, these results are useful as they reflect real-
world practice in a typical clinical patient cohort. In addition, the
sample numbers were small, and there was a sizable loss of data
as we removed 18.2% of eligible subjects from analysis because
of incomplete pre/post-ECT BPRS scores, although there was no
evidence that these patients differed from those in whom complete
data were available as there were no significant differences between
the groups on clinical and demographic variables. The small patient
numbers in each ECT group precluded formal comparison of the
different ECT modalities in terms of treatment outcomes.
CONCLUSIONS
Electroconvulsive therapy in general and also specifically
RUL-UB ECT were effective in treating an acute manic episode,
reducing symptom burden and improving global cognition. These
results are promising but preliminary, given the small sample num-
bers involved. Further studies in larger cohorts, examining effective-
ness and cognitive outcomes of RUL-UB ECT and other modalities
of ECT in treating mania, would provide useful clinical information
on the relative utility of the RUL-UB ECT treatment approach.
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