title: Electroconvulsive therapy in the treatment of mixed states in bipolar disorder.
abstract: BACKGROUND
  Mixed bipolar states are not infrequent and may be extremely difficult to treat. Lithium, anticonvulsants including valproate and carbamazepine, and antipsychotics such as olanzapine, ziprasidone, and aripiprazole have been reported to be at least partially effective in controlled clinical trials, but many patients do not respond to pharmacological approaches. Electroconvulsive therapy has been tested to be efficacious for the treatment of both manic and depressive episodes, but much less evidence is available with regards to mixed states. The aim of the review was to report the available evidence for the use of electroconvulsive therapy in mixed bipolar states.
  
  
  METHODS
  A systematic review of the literature on treatment of mixed states, focused on electroconvulsive therapy, was made, beginning in August 1992 and ending in March 2007. The key words were "electroconvulsive therapy" and "mixed bipolar".
  
  
  RESULTS
  Only three studies met the required quality criteria and were included. This literature suggests that ECT is an effective, safe, and probably underutilized treatment of mixed states. Recent technical developments have made ECT more friendly, tolerable, and safe. Potential alternatives, such as vagus nerve stimulation, deep brain stimulation, or transcranial stimulation, are still far to be proved as effective as ECT.
authors.affiliation: Bipolar Disorders Program, Institute of Clinical Neuroscience, Hospital Clinic, University of Barcelona, IDIBAPS, CIBER-SAM, Villarroel 170/Rossello 140, 08036 Barcelona, Catalonia, Spain.
authors.forename: Marc
authors.initials: M
authors.lastname: Valentí
authors.forename: Antoni
authors.initials: A
authors.lastname: Benabarre
authors.forename: Margarita
authors.initials: M
authors.lastname: García-Amador
authors.forename: Oriol
authors.initials: O
authors.lastname: Molina
authors.forename: Miquel
authors.initials: M
authors.lastname: Bernardo
authors.forename: Eduard
authors.initials: E
authors.lastname: Vieta
mesh_terms: D001714:Bipolar Disorder / Q000175:diagnosis / Q000523:psychology* / Q000628:therapy*; D002986:Clinical Trials as Topic / Q000706:statistics & numerical data; D003866:Depressive Disorder / Q000175:diagnosis / Q000523:psychology / Q000628:therapy*; D039721:Diagnostic and Statistical Manual of Mental Disorders; D004565:Electroconvulsive Therapy; D006801:Humans; D011446:Prospective Studies; D011569:Psychiatric Status Rating Scales / Q000706:statistics & numerical data; D016896:Treatment Outcome