To the Editor: ECT is an effective and safe treatment for acute manic phases of bipolar disorder.¹ Lithium has been widely used for bipolar disorder because of its efficacy in managing acute mood episodes, preventing relapse, and reducing suicide risk.² However, a few case reports have cautioned that the concurrent use of lithium in patients undergoing ECT may cause severe cognitive disturbance, respiratory complication, or prolonged seizures.³ However, Dolenc and Rasmussen³ describe 12 patients in whom the combination of lithium and ECT was deemed safe. It may be idiosyncratic. We report the case of a bipolar I disorder patient with aggressive violence successfully treated with lithium combined with ECT without complication. This case report may provide an adjunctive treatment of an acute manic stage.

A 50-year-old Taiwanese woman was admitted for psychiatric inpatient treatment because of bipolar I disorder. The patient presented the symptoms of elevated mood, pressured speech, flight of ideas, grandiose delusion, and predominant aggressive violent behavior for 2 months despite treatment with lithium, 900 mg per day. She denied history of drug abuse or cardiovascular disease. Initial laboratory studies revealed normal ranges. The Young Mania Rating Scale (YMRS) total score was 49 on the first hospital day. However, treatment with lithium seemed to be ineffective, and the YMRS total score was 46 on the eighth hospital day. Following this condition, we added ECT three times per week for our patient. She also underwent cardiac, odontological, and neurological evaluations to identify any possible clinical conditions counterindicating ECT. Then, she received lithium combined with bilateral ECT at an electrical dose of 30% energy using the Thymatron DGx model IV. Surprisingly, the aggressive behavior subsided and the YMRS total score was improved to 7 after two sessions of ECT. The mean seizure duration, as assessed by clinical observation, was 26 seconds, whereas the total seizure duration was 52 seconds. The blood lithium level maintained 0.71 and 1.05 meq/liter. However, no prolonged seizures, postical delirium, or respiratory complications were noted.

ECT has been in use since 1938 to treat a variety of mental illness, but the definite mechanism has yet to be understood in detail.⁴ This case reported that ECT combined with lithium can safely and rapidly control manic symptoms. Bipolar disorder has been implicated in increased rates of violent behavior, especially during the manic phase. For the acute manic patient, we should consider the risk of aggressive violent behavior of abruptly discontinued lithium. Therefore, we might consider the combination of ECT with lithium for rapid management of manic symptoms before the clinical response to lithium, if there is no contraindication. Our findings do not imply that lithium had to be administered concurrently with ECT for these patients. Blood levels of lithium should be closely monitored while continuing maintenance ECT, and a washout period is necessary for high levels of lithium. In the future, it would interesting to undertake a study of potential differential effects of ECT combined with lithium versus lithium alone for acute manic patient.