To the Editor: In their Clinical Case Conference, Cheryl A. Green, M.D., et al. (1) described a homeless patient with bipolar disorder who had committed two very serious acts of self-mutilation: a near-amputation of his right arm and, 15 years later, an attempted self-enucleation of his right eye. In the intervening years, he had been hospitalized multiple times; several admissions had lasted longer than 10 months; his average length of stay had been approximately 4 months. His medications included one or more mood stabilizers, a neuroleptic, and a benzodiazepine. It appears that this patient, despite his very severe illness and prolonged hospitalizations, was never given ECT.