Treatment Resistant Depression in Bipolar Disorder - A Randomized Controlled Trial of Electroconvulsive Therapy

Inclusion Criteria: * ECT indicated * Diagnosis of DSM-IV-TR of Bipolar I or Bipolar II disorder as verified by the semi-structured diagnostic interviews SCID or MINI plus. * Severity: meet DSM-IV-TR criteria of depressive episode, MADRS of 25 or above. * Treatment resistance * None response to two trials (during lifetime) with mood stabilizer with proven efficacy in bipolar depression (lithium, lamotrigine, quetiapine, olanzapine) and /or antidepressants. * A trial is defined as at least 6 weeks in adequate or tolerated dose as reported by the patient, or patients that have been unable to comply with 6 weeks trials of mood stabilizer or an antidepressant. * Less than 50% reduction in MADRS values or still meet DSM -IV-TR criteria of depressive episode * Inpatients the first week after start of treatment condition * The patient are to be treated by the psychiatrist at the hospital for the whole duration of the study (6 weeks) * Age ≥ 18 * Patient competent to give informed consent according to the judgement of the clinician * Written informed consent * Patient fluent in Norwegian language Exclusion Criteria: * Earlier ECT nonresponse * ECT within the last six months * More than four failed adequate medication trials in the current episode * Rapid cycling bipolar disorder (e.g.4 or more episodes per year) * Use of medication or substances (such as pethidine, alcohol, drugs) incompatible with drug medication or ECT. Such medication must be stopped a least 5 half-lives before inclusion in the study. * Current use of all other psychotropic medication 5 t1/2 before inclusion and during the study period with the exception of the following: * The use of alimemazine (max dose 30 mg daily), chlorpromazine (max dose 25 mg x 2 daily) and chlorprotixen (max dose 20 mg x 2) is allowed. The use of mianserin (max dose 10 mg daily) is allowed. Such medication has to been discontinued at least 2 days prior neuropsychological assessment. Medication related to the ECT procedure is allowed. * Inability to comply with study protocol * Unstable serious medical conditions, including clinically relevant laboratory abnormalities * Conditions that affect neuropsychological assessment such as Parkinson's Disease, Multiple sclerosis, stroke, alcohol and substance abuse or dependence (according to SCID or DSM-IV-TR) * Pregnancy or lactation * Fertile women without adequate contraception (Adequate contraception includes: abstinence, oral contraceptives, intrauterine devices, barrier method) * YMRS of 20 or more * Patient at high suicidal risk according to clinicians' judgment