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Am J Psychiatry. 2015 Jan;172(1):41-51. doi: 10.1176/appi.ajp.2014.13111517. Epub 2014 Oct 31.

Treatment-resistant bipolar depression: a randomized controlled trial of electroconvulsive therapy versus algorithm-based pharmacological treatment.

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From the Division of Psychiatry and the Research Department, Stavanger University Hospital, Stavanger, Norway; the Division of Psychiatry, Haukeland University Hospital, Bergen, Norway; the Institute of Clinical Medicine and Neuropsychiatry, the Department of Emergency Mental Health Services, and the Gerontopsychiatric Unit, Oslo University Hospital, Ullevaal, Norway; the Østmarka Department of Psychiatry, St. Olav University Hospital of Trondheim, Trondheim, Norway; the Psychiatry Clinic, Oslo University Hospital, Aker, Norway; and the Psychiatry Clinic, Østfold County Hospital, Fredrikstad, Norway.



Electroconvulsive therapy (ECT) is regarded by many clinicians as the most effective treatment for treatment-resistant bipolar depression, but no randomized controlled trials have been conducted, to the authors' knowledge. They compared efficacy measures of ECT and algorithm-based pharmacological treatment in treatment-resistant bipolar depression.


This multicenter, randomized controlled trial was carried out at seven acute-care psychiatric inpatient clinics throughout Norway and included 73 bipolar disorder patients with treatment-resistant depression. The patients were randomly assigned to receive either ECT or algorithm-based pharmacological treatment. ECT included three sessions per week for up to 6 weeks, right unilateral placement of stimulus electrodes, and brief pulse stimulation.


Linear mixed-effects modeling analysis revealed that ECT was significantly more effective than algorithm-based pharmacological treatment. The mean scores at the end of the 6-week treatment period were lower for the ECT group than for the pharmacological treatment group: by 6.6 points on the Montgomery-Åsberg Depression Rating Scale (SE=2.05, 95% CI=2.5-10.6), by 9.4 points on the 30-item version of the Inventory of Depressive Symptomatology-Clinician-Rated (SE=2.49, 95% CI=4.6-14.3), and by 0.7 points on the Clinical Global Impression for Bipolar Disorder (SE=0.31, 95% CI=0.13-1.36). The response rate was significantly higher in the ECT group than in the group that received algorithm-based pharmacological treatment (73.9% versus 35.0%), but the remission rate did not differ between the groups (34.8% versus 30.0%).


Remission rates remained modest regardless of treatment choice for this challenging clinical condition.


[Indexed for MEDLINE]

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