Recent evidence favors the view of catatonia as an autonomous syndrome, frequently associated with mood disorders, but also observed in neurological, neurodevelopmental, physical and toxic conditions. From our systematic literature review, electroconvulsive therapy (ECT) results effective in all forms of catatonia, even after pharmacotherapy with benzodiazepines has failed. Response rate ranges from 80% to 100% and results superior to those of any other therapy in psychiatry. ECT should be considered first-line treatment in patients with malignant catatonia, neuroleptic malignant syndrome, delirious mania or severe catatonic excitement, and in general in all catatonic patients that are refractory or partially responsive to benzodiazepines. Early intervention with ECT is encouraged to avoid undue deterioration of the patient's medical condition. Little is known about the long-term treatment outcomes following administration of ECT for catatonia. The presence of a concomitant chronic neurologic disease or extrapyramidal deficit seems to be related to ECT non-response. On the contrary, the presence of acute, severe and psychotic mood disorder is associated with good response. Severe psychotic features in responders may be related with a prominent GABAergic mediated deficit in orbitofrontal cortex, whereas non-responders may be characterized by a prevalent dopaminergic mediated extrapyramidal deficit. These observations are consistent with the hypothesis that ECT is more effective in "top-down" variant of catatonia, in which the psychomotor syndrome may be sustained by a dysregulation of the orbitofrontal cortex, than in "bottom-up" variant, in which an extrapyramidal dysregulation may be prevalent. Future research should focus on ECT response in different subtype of catatonia and on efficacy of maintenance ECT in long-term prevention of recurrent catatonia. Further research on mechanism of action of ECT in catatonia may also contribute to the development of other brain stimulation techniques.

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Objective:We evaluated the effectiveness of Electroconvulsive Therapy (ECT) in the treatment of Bipolar Disorder (BD) in a large sample of bipolar patients with drug resistant depression, mania, mixed state and catatonic features.Method:522 consecutive patients with DSM-IV-TR BD were evaluated prior to and after the ECT course. Responders and nonresponders were compared in subsamples of depressed and mixed patients. Descriptive analyses were reported for patients with mania and with catatonic features.Results:Of the original sample only 22 patients were excluded for the occurrence of side effects or consent withdrawal. After the ECT course, 344 (68.8%) patients were considered responders (final CGIi score ≤2) and 156 (31.2%) nonresponders. Response rates were respectively 68.1% for BD depression, 72.9% for mixed state, 75% for mania and 80.8% for catatonic features. Length of current episode and global severity of the illness were the only statistically significant predictors of nonresponse.Conclusion:ECT resulted to be an effective and safe treatment for all the phases of severe and drug-resistant BD. Positive response was observed in approximately two-thirds of the cases and in 80% of the catatonic patients. The duration of the current episode was the major predictor of nonresponse. The risk of ECT-induced mania is virtually absent and mood destabilization very unlikely. Our results clearly indicate that current algorithms for the treatment of depressive, mixed, manic and catatonic states should be modified and, at least for the most severe patients, ECT should not be considered as a “last resort”.

The "ideal" mood stabilizer has been defined as an agent displaying demonstrated efficacy for the acute treatment and long-term prevention of both mania and depression. On the basis of a selective and an extensive review of the existing literature primarily focused on prospective and controlled studies, we discuss the potential mood-stabilizing effects of electroconvulsive therapy (ECT) and its efficacy for the acute treatment of bipolar depressive and mixed-manic states and the prevention of all types of recurrences of bipolar disorder (BD). We conclude that ECT should be considered an effective acute treatment for the depressive and manic-mixed states of BD, as ECT displays response and remission rates superior to those of other treatment approaches, even in severe and treatment-resistant cases. From this point of view, its clinical mood-stabilizing effects are clearly superior compared with other pharmacological approaches because most treatments that alleviate bipolar depression can cause mania, hypomania, mood instability, or rapid cycling and treatments that can control mania can induce or precipitate depressive symptoms or episodes. The ECT-induced mania is rare, and there are no data suggesting possible long-term mood destabilization, including cycle induction or acceleration. Conversely, several case reports and open trials reported a significant reduction in morbidity among patients experiencing rapid-cycling BD. Regarding relapse prevention, c-ECT and m-ECT are considered as appropriate therapies for treatment-resistant patients exhibiting high rates of depressive or mixed relapse. Further investigation is necessary to identify the frequency and duration of continued treatment after a successful index course of ECT.