Electroconvulsive therapy (ECT) remains one of the most effective treatments we have to treat depression. Acute response rates for ECT are consistently higher than response rates generally reported in clinical trials for antidepressant medications. This observation is doubly impressive knowing that patients who today receive ECT for an index episode of depression typically have failed 2 or more antidepressant medication trials.

The bipolar pharmacopoeia has steadily increased over the past 10 years. The US Food and Drug Administration (FDA) has approved 10 treatments for mania, 4 treatments for the maintenance phase of bipolar disorder, and 2 for bipolar depression. With these substantial clinical advances, it is often forgotten how effective ECT is for bipolar depression, depression with a switch into mania (ECT treatment through the mania), refractory mania, and maintenance ECT for bipolar disorder. Although it would be difficult to study with a controlled comparative design, many clinicians think that ECT is still the best mood stabilizer we have to date. Given the need for anesthesia and the potential for cognitive deficits as a side effect, ECT for bipolar depression, as with unipolar depression, has been viewed less as first-line agent and thus reserved for refractory cases.

However, ECT may be the treatment of choice for bipolar mania or depression in pregnancy to avoid potential teratogenicity related to pharmacotherapy. In addition, for bipolar patients with a compromised nutritional status who acutely become catatonic or severely depressed, and the delay of several weeks for antidepressant response is not an option, ECT would be a first-line agent. For a review of these data, see Bonds and colleagues.