An Examination of Electroconvulsive Therapy and Delivery of Care in Delirious Mania

Abstract

Objectives: Delirious mania is a severe life-threatening syndrome, often misdiagnosed, and eminently treatable as a variant of catatonia. Our aim is to provide a comprehensive examination of electroconvulsive therapy (ECT) parameters and clinical features, as well as describe the delivery of care of the patients with delirious mania.Methods: A retrospective study was conducted of the ECT records at Stony Brook University Hospital from years 2014 to 2021. We characterized demographic and clinical variables, including psychiatric diagnoses and ECT parameters of patients identified with delirious mania. Results:We identified 8 cases (3 women) of delirious mania with 8 corresponding acute treatment series. The mean age was 43.2 ± 12.6 years (range, 23-59 years). There were a total of 55 sessions performed with an average of 6.9 ± 2.6 (range, 5-13); 45 (82%) were bilateral (bifrontal or bitemporal) and 10 (18%) were right unilateral electrode placement. In 40 (73%) of the sessions, a high-energy stimulus was used (>60%, or 302 millicoulombs). Seizure duration measured on electroencephalogram was 47.4 ± 25.9 seconds (range, 0-143 seconds). Motor seizure duration measured on electromyogram was 32.7 ± 14.9 seconds (range, 0-66 seconds). In 6 cases, ECT was delayed for 10 days, and patients were given inappropriate treatments. High-dose antipsychotics caused worsened aggression and hemodynamic instability requiring physical restraints in 50% of cases. Conclusions:The clinical presentation of delirious mania remains poorly recognized, and its treatment is often delayed, which may result in negative outcomes. Bilateral ECTwith high-energy dosing yielded a rapid remission of symptoms.

Clinical Characteristics and Treatment Responses of Patients in Delirious Mania: A Case Series

“…The clinical picture might indicate an exploration of the differentials of drug toxicity, metabolic disorders, and central nervous system infections. Electroconvulsive therapy and high-dose benzodiazepines provide effective management of DM [ 10 , 11 ]. Putative aetiologies of DM include the following:…”

Electroconvulsive therapy (ECT) for mania: Hiding in plain sight

“…10 The rare, and most severe, form of mania, delirious mania, is an urgent medical situation, and one in which timely application of ECT may be life-saving. 11 What about technical aspects of ECT for manic episodes? Popiolek and colleagues report that about half of the patients in their analysis received right unilateral (RUL) ECT; they noted this as a potential limitation, suggesting that the high ECT response rates they reported might have been even higher, had more patients been treated with bilateral electrode placement.…”

“…The complicating factor of obtaining fully informed consent from an acutely manic patient only adds to the restricted use of ECT in such situations 10 . The rare, and most severe, form of mania, delirious mania, is an urgent medical situation, and one in which timely application of ECT may be life‐saving 11 …”