CASE REPORT
Ultrabrief Electroconvulsive Therapy for Manic
Episodes of Bipolar Disorder
Sandip Anand, MD, FRANZCP
Abstract: Right unilateral ultrabrief-pulse electroconvulsive therapy
(RUL-UB ECT) is gaining popularity and is being used for the treatment
of severe major depression. Though brief pulse-width ECT has shown to
have robust antimanic effects, the efficacy of UB ECT for mania has not
been studied, and there are very few reports on its use in mania. A brief case
series of 3 patients with manic episode of bipolar disorder who were treated
with RUL-UB ECT is presented here. The successful treatment of
2 patients in this report suggests that some manic episodes can be rapidly
and effectively treated with RUL-UB ECT.
Key Words: ultrabrief, right unilateral, electroconvulsive therapy,
mania, bipolar disorder
(J ECT 2016;00: 00–00)
B rief pulse-width (typically 1.0 ms) electroconvulsive therapy
(ECT) has been the standard in modern clinical ECT practice,
but there is emerging evidence that ultrabrief pulse width ECT
(UB ECT) (pulse width of less than 0.5 ms) may lead to clinically
meaningful efficacy,1 while reducing cognitive side effects when
given at higher dosages than brief pulse ECT.2 Right unilateral
ultrabrief-pulse ECT (RUL-UB ECT) is thus being increasingly
studied for its efficacy and adverse effect profile and is gaining
popularity for the treatment of severe major depression. Apart
from 1 study by Pisvjec and colleagues3 that included patients
with schizophrenia, all other studies have focused exclusively on
UB ECT for depression. Successful treatment of mania with
ECTwas described as early as the 1940s.4 However, ECT in mania
is less researched when compared with ECT in depression and is
less commonly used. Though the paucity of ECT research in bipo-
lar disorders was noted by Versiani and colleagues,5 a review by
Loo and colleagues6 concluded that ECT is an effective treatment
for acute mania based on available studies. With UB ECT show-
ing evidence in treating major depression, it will be important
to study its efficacy in treating acute mania. A literature search
showed a case discussion of successful treatment of a manic epi-
sode of bipolar disorder with ultrabrief ECT7 after 6 treatments.
However, the article did not give any details of ECT parameters
used and focused more on the use of ECT in mania than the as-
pect of pulse width. A case report described the successful use
of UB ECT in 1 patient with mixed affective episode of bipolar
disorder with 9 treatments.8 A case series of 13 patients with cat-
atonia treated with UB ECT has described 1 patient each with a
manic episode and a mixed episode though their primary presen-
tation was with catatonia in which the former improved and re-
ceived 15 treatments whereas the latter did not.9
This short case series describes the use of RUL-UB ECT for
treatment of manic episodes of bipolar affective disorder in 3 in-
patients. The ultrabrief pulse width was 0.3 ms and treatments
From the Mater Mental Health Centre, NSW, Australia.
Received for publication December 15, 2015; accepted March 3, 2016.
Reprints: Sandip Anand, MD, FRANZCP, Staff Specialist Psychiatrist, Mater
Mental Health Centre, Newcastle Mental Health, Edith St, Waratah, NSW
2298, Australia (e‐mail: sandip.dr@hotmail.com).
The author has no conflicts of interest or financial disclosures to report.
Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/YCT.0000000000000323
Journal of ECT • Volume 00, Number 00, Month 2016
Copyright © 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
were given at 6 times seizure threshold. All 3 patients received
thrice weekly treatment. The treatment parameters of each case
are described in Table 1.
CASE 1
Mr KC, a 21-year-old man was admitted involuntarily for a
first episode of mania with psychotic symptoms. He was elated,
irritable, overtalkative, hyperactive, disinhibited, overfamiliar, and
intrusive and had reduced sleep with grandiose and persecutory
delusions. After a 3-week treatment in hospital with risperidone
tablet up to 4 mg/d and valproate tablet 1000 mg/d, he improved
partially and was discharged at the request of his supportive par-
ents. However, he was readmitted within a week after a worsen-
ing of his manic symptoms despite reported compliance with
treatment. Increase in dose of risperidone to 6 mg/d and valproate
1500 mg/d along with administration of a dose of zuclopenthixol
acetate 100 mg intramuscularly led to the development of extra-
pyramidal symptoms of tremor and rigidity. In view of only
partial improvement with pharmacotherapy, side effects from
antipsychotics and the family's distress and request for faster im-
provement, valproate was stopped, and RUL-UB ECT was com-
menced after approval from the Mental Health Review Tribunal
(MHRT). Seizure threshold was established at 4% during the
first session, with suprathreshold treatments given at 25% dur-
ing each of the next 4 sessions. The ECT parameters were as
shown in Table 1. Manic symptoms measured using Young Mania
Rating Scale10 (YMRS) dropped by 36 points from pre-ECT to
after the fifth treatment. He did not have any major side effects
from ECT. After cessation of ECT, he was discharged from hos-
pital on lithium carbonate as a prophylactic medication and main-
tained improvement at 12 months posttreatment.
CASE 2
Ms SA, a 52-year-old lady with a history of bipolar affective
disorder was admitted involuntarily for a recurrence of mania
with psychotic symptoms, the main trigger for which appeared
to have been the prescription of fluvoxamine 50 mg/d in addition
to her usual dose of carbamazepine 400 mg/d and quetiapine XR
200 mg/d. She was previously not known to the local mental
health team. History revealed at least 3 previous manic episodes
and prophylaxis with lithium and valproate at some stage, with
no other details known. On assessment, she was elated, expansive,
hyperactive, and overfamiliar and had grandiose and religious de-
lusions. Collateral history from her carer suggested that she usu-
ally had prolonged manic episodes with a very gradual reduction
of symptoms over many months. Fluvoxamine was stopped, car-
bamazepine 400 mg/d was continued, and quetiapine XR was in-
creased up to 800 mg/d for 3 weeks with minimal improvement.
Quetiapine XR was later changed to risperidone (up to 6 mg/d)
and carbamazepine to lithium carbonate (up to 1350 mg/d), with
a serum lithium level of 0.9mmol/L. Due to erotomanic delusions
that an ambulance officer was in love with her, she repeatedly tried
communicating with the ambulance department through letters
and phone calls and inviting people for her grand wedding. In
view of slow and inadequate improvement with pharmacotherapy,
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Anand et al
TABLE 1. Description of Cases, Total Treatments (After Determining Threshold), Treatment Parameters and EEG Seizure Parameters
Case Age, y Sex Diagnosis and Brief Presentation
1 21 M Mania with psychotic symptoms;
slow improvement with
pharmacotherapy
2 52 F Bipolar affective disorder, manic
with psychotic symptoms; slow
improvement with pharmacotherapy
3 65 F Bipolar affective disorder, manic
with psychotic symptoms; patient
reluctance to try pharmacotherapeutic
options other than Quetiapine XR
TT, total treatments; TP, treatment parameters—pulse width (ms)/energy (%)/charge (mC)/pulse frequency (Hz)/current (mA); EP: electroencephalo-
gram (EEG) seizure parameters—duration (s)/postictal suppression index (%)/interhemispheric coherence (%).
her vulnerability and the risk of harm to her reputation, it was
decided to give her ECT. After approval from the MHRT, she
was treated with 9 sessions of RUL-UB ECT. Lithium carbonate
was stopped before commencement of ECT and was restarted
after cessation of ECT. The ECT parameters were as shown in
Table 1. She started showing improvement after the third ECT.
Manic symptoms measured by the YMRS dropped by 22 points
from pre-ECT to the sixth ECT and to zero after the ninth ECT.
The ECT dose was increased twice, after fifth and eighth treat-
ments, when there was a decline in electroencephalogram seizure
quality. She remained in hospital for 2 weeks after cessation of
ECT, and her improvement was maintained at 2 months posttreat-
ment after which she moved out of area.
CASE 3
Ms DC, a 65-year-old lady with a longstanding bipolar affec-
tive disorder with onset in her early 50s, presented to our hospi-
tal with a manic episode with psychotic symptoms. A recent
reduction of her quetiapine XR from 400 to 300 mg daily along
with psychosocial stressors appeared to have triggered the onset
of the manic episode. Assessment after admission showed ele-
vated mood with grandiose and persecutory delusions. Increasing
quetiapine XR to 400 mg/d and later to 600 mg/d failed to achieve
significant improvement. She was strongly opposed to having
any other medications including lithium carbonate or sodium
valproate owing to side effects from them in the past and was
therefore treated with RUL-UB ECT after approval from the
MHRT. After determining seizure threshold at 8%, she was treated
with 6 more sessions of RUL ECT as mentioned in Table 1, with
5 being UB. The improvement with RUL ECT was partial and
seizure quality deteriorated over the 6 treatments necessitating
dose increase to 50%, 90%, and 150%. Treatment was therefore
changed to bitemporal ECT and dose decided based on the half
of age method, with 2 more treatments at 35% and 50%. The
YMRS score before starting RUL-UB ECT was 38 which dropped
by 17 points before treatment was changed to RUL brief pulse
ECT due to decline in seizure quality. On further change to
bitemporal ECT, there was more improvement with the patient
achieving complete resolution of symptoms after 2 bitemporal
treatments.
DISCUSSION
This short case series describes 3 cases of mania with psy-
chotic symptoms treated with RUL-UB ECT. The first 2 cases
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Journal of ECT • Volume 00, Number 00, Month 2016
TT TP (ms/%/mC/Hz/mA) EP (s/%/%)
4 0.3/25/126/30/900—4 treatments 53.3/93.5/84.4
8 0.3/25/126/30/900—4 treatments 29.8/51.9/90.9
0.3/50/250/60/900—3 treatments
0.3/90/450/110/900—1 treatment
10 0.3/25/126/30/900—1 treatment 31/47.9/83.9 (ultrabrief )
0.3/50/250/60/900—4 treatments 31.5/64.3/79.9
0.3/90/450/110/900—1 treatment (brief pulse unilateral)
1/150/760/70/900—2 treatments 31/88.1/98.1
1/35/178/50/900—1 treatment (brief pulse bitemporal)
1/50/253/50/900—1 treatment
were successfully treated with complete resolution of symptoms,
whereas the third case responded partially but had to be changed
to bitemporal brief pulse ECT during the course of treatment.
For the first patient, young age and first episode of mania could
have helped in achieving suprathreshold treatment at the same
ECT dose throughout the course of treatment with the subse-
quent quick response and resolution of symptoms. This indicates
that there may be a subgroup of manic patients whose speed of
response with UB ECT may be comparable to brief pulse ECT
while minimizing cognitive side effects. The second patient also
had complete resolution of symptoms though she required more
treatments and 2 dose increases due to fall in seizure quality.
Though the third patient had a partial improvement in manic
symptoms with UB ECT, the treatment had to be changed to brief
pulse RUL and later bitemporal due to rapid decline in seizure
quality. One of the issues as highlighted by this case is the need
to decide the ECT dose on changing from unilateral to bitemporal
ECT during the course of treatment. This may be done using the
titration method or the “half of age” method and may be influ-
enced by the need for rapid response, potential for cognitive and
cardiovascular side effects, and legislative restriction on number
of ECT treatments. In keeping with the existing knowledge that
RUL-UB ECT causes lesser cognitive side effects than brief
pulse ECT, none of the three patients had any major cognitive
side effects with UB ECT but the third patient reported some
short-term memory deficits after change to bitemporal ECT.
ECT has shown to have robust antimanic effects but is
not often considered as a treatment of first choice for mania.11
The main reason for this appears to be the paucity in research
which may be due to various reasons including difficulty in ad-
ministering ECT to an uncooperative and agitated manic patient,
faster treatment response of mania to antipsychotics than depres-
sion to antidepressants, and legislative requirements. Though uni-
lateral ECT has shown efficacy in mania based on retrospective
studies and case reports, most of the prospective studies of ECT
in mania have used bilateral ECT, especially studies in the last de-
cade.12 The UB ECT is a relatively new and increasingly used
technique for treatment of unipolar and bipolar depression. Evi-
dence for the use of UB ECT in mania is scanty. It is unclear if pa-
tients receiving UB ECT for mania may have a slower speed of
response and require additional treatments when compared with
brief pulse ECT. The 2 successfully treated cases in this series sug-
gest that this may not always be the case. More research evidence
is obviously needed before this can be definitely established
though controlled studies are often difficult to perform.
© 2016 Wolters Kluwer Health, Inc. All rights reserved.
Journal of ECT • Volume 00, Number 00, Month 2016
Legislative requirements may pose a hurdle to conducting
controlled trials on UB ECT for mania. Unlike depressed patients,
manic patients are less likely to give informed consent for the
use of ECT. External approval by a competent authority is usually
needed for using ECT to treat mania when the patient is either in-
competent or refusing to give consent, which is hard to come by
when clinical practice guidelines are restrictive and up-to-date re-
search evidence is scanty. Clinical practice guidelines often do
not reflect the up-to-date evidence available, posing a handicap
to clinicians. The National Institute of Clinical Excellence, for
example, suggests that ECT should be used only for “a prolonged
or severe episode of mania”, “after all other treatment options have
failed,” or when the situation is thought to be life-threatening.”13
All 3 patients in this series were given ECT after approval by a
mental health review tribunal. Such consent may be difficult to
obtain for controlled studies of ECT in mania.
Although refinement of the ECT technique over the years
has improved the aesthetic aspect of ECT administration, lower-
ing the possibility of cognitive side effects with UB ECT may fur-
ther improve the stigma attached to it and enable more research. If
UB ECT can lead to clinically meaningful efficacy with lesser
cognitive side effects in mania, it may offer a faster-acting treat-
ment alternative with lesser side effects than pharmacotherapy
for many patients. This case series adds to the growing literature
on the use of RUL UB ECT in manic episodes of bipolar dis-
order. Growing suggestions of its efficacy may encourage and
support the conduct of controlled studies comparing UB ECT to
pharmacotherapy and to brief pulse ECT in acute mania.
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