My personal thoughts would be that I would only want ECT for mania if no antipsychotics worked, after multiple aggressive trials. Or, if I was in a catatonic state resulting from mania, or in an extremely medication resistant situation where I was a persistent risk to myself or others. Extreme manic episodes, with mixed features, may also be episodes that might convince me to have ECT. In these cases, it may be good that a person has such preferences outlined in a Psychiatric Advance Directive. After all, if you are really so manic, you may not be capable of really making such a decision.

I did have a 3-year period when I was becoming manic again and again with only short reprieves (a rapid cycling year). I don't know, perhaps if I knew then what I know now I would have elected for ECT. But back then, I always assumed it would stop for a long time during those reprieves. How do you really know when/if the next manic episode (or depression) will start? I am not usually a rapid cycler in the way that many people are. Maybe if I was I'd consider that.

The very first time ECT was recommended to me was during a period when I was often between hypomania and mania, and had been hospitalized already maybe six times, or so. My psychiatrist recommended it and I said no, that I wanted to try more medications. Then another time, maybe during my next hospitalization after that, ECT was recommended again. I was in a mania with mixed episodes that time. I remember leaving what was an inpatient NP's office and having a violent tirade at the nurse's station. I was dragged into the isolation room and given an injection, and left there for a while (door locked). I still refused. Then maybe one more hospitalization went by where I was extremely manic with terrible psychosis. I don't recall much of anything. I had a manic blackout that time. [I had had some manic blackouts before, as well.] I don't think I was in any state of mind to be saying "yes" to anything like ECT.

After a long string of manias, I did eventually crash, in a very bad way, into a pure depressive period. Then the depression was relentless. Just as I had historically been more willing to go to doctors during depressions, I was more willing to consider ECT. The third time it was suggested, I agreed. That was the only time I have had a series of ECT treatments. My depression that time had gone on for a while and was severe, though not so severe that I couldn't make my own decisions. Some people can't decide even during severe depression, especially if it is so severe that you can't function AT ALL. That's another reason to figure out when you might consider it, and state that in a Psychiatric Advance Directive.