Electroconvulsive Therapy (ECT) in Bipolar Disorder Patients with Ultra-Rapid Cycling and Unstable Mixed States

The effectiveness of electroconvulsive therapy (ECT) for people with bipolar disorder: is there a specific role?

INTRODUCTION

Electroconvulsive therapy (ECT) has been used for over 80 years to treat various neuropsychiatric conditions, including mood and psychotic disorders. Despite its proven efficacy, ECT remains underutilized and underexplored in patients with bipolar disorder (BD).

AREAS COVERED

This perspective examines the role of ECT in BD, highlighting its effectiveness across depressive, manic, and mixed phases, including those characterized by catatonic or delirious features. Based on these findings, the authors propose a comprehensive transdiagnostic framework to conceptualize ECT-responsive syndromes based on psychomotor, psychotic, and cognitive disturbances. The potential long-term effectiveness of ECT as a mood stabilizer is also suggested, despite the limited amount of literature. Finally, safety issues and alternative options are discussed.

EXPERT OPINION

The shift in ECT usage, from being a first-line treatment for severe affective episodes to a 'last-resort' option for treatment-resistant depression, may have contributed to increased relapse rates and chronicity. Considering ECT at an early stage, potentially even before any medication trials, is recommended for specific clinical conditions associated with BD and marked by objective psychomotor disturbances, acute psychotic symptoms, and severe cognitive alterations.

Risk factors for electroconvulsive therapy-induced fever: a retrospective case-control study

Background

Electroconvulsive therapy (ECT)-induced fever can significantly affect patient experience, treatment adherence, and the course of treatment. However, little is known about the prevalence of ECT-induced fever and its associated risk factors in patients with major mental disorders (MMD).

Methods

This retrospective, case-control study included 113 cases and 226 age-matched controls (1:2). The case group comprised patients who exhibited an axillary temperature of ≥37.5°C (99.5°F) at least once within 24 hours post-ECT. Patients diagnosed with MMD underwent ECT between January 1, 2021, and December 31, 2021, at a large psychiatric hospital in China. Demographic and clinical data were extracted from the electronic chart management system (ECMS) for both groups.

Results

The prevalence of ECT-induced fever in patients with MMD was 6.8% [113/1,674, 95% confidence interval (CI): 5.6% to 8.0%], with a session-based prevalence of 1.1% (130/11,570, 95% CI: 0.9% to 1.3%). Multivariate logistic regression analysis identified paliperidone [odds ratios (OR)=2.5, 95% CI: 1.2 to 4.9] as a risk factor, while quetiapine (OR=0.4, 95% CI: 0.3 to 0.8) was found to be protective. No significant association between etomidate and ECT-induced fever was observed in univariate analysis (p>0.05).

Conclusions

This study found a relatively low prevalence of ECT-induced fever. Paliperidone was identified as a risk factor, while quetiapine had a protective effect. Etomidate was not significantly associated with ECT-induced fever in patients with MMD.

Achieving Response With Bolus Dosing of Valproate in Electroconvulsive Therapy (ECT)-Induced Mania: A Case Report

Electroconvulsive therapy (ECT) is an effective treatment for various mental illnesses. While it is an excellent modality in treating depression and severe mania, it can also induce mania in certain specific settings. There is so far scarce literature regarding the management of ECT-induced mania with antipsychotics and mood stabilizers, specifically lithium, utilized in different studies. Moreover, there is limited evidence for using valproate for the symptoms. We present a case vignette about managing mania symptoms after ECT by administering a bolus dose of valproate at each session, resulting in progressively improved outcomes.

Sociodemographic, clinical and treatment characteristics of current rapid-cycling bipolar disorder: a multicenter Chinese study

BACKGROUND

Rapid cycling bipolar disorder (RCBD), characterized by four or more episodes per year, is a complex subtype of bipolar disorder (BD) with poorly understood characteristics.

METHOD

This multicenter, observational, longitudinal cohort study enrolled 520 BD patients across seven psychiatric institutions in China from January 2013 to January 2014. Participants were divided into RCBD and non-RCBD (NRCBD) groups based on the frequency of mood episodes in the preceding year. Data collection utilized a standardized form, supplemented by a medical record review, focusing on sociodemographic, clinical, and treatment characteristics. Statistical analysis involved independent samples t-tests, Kruskal-Wallis H tests, Chi-square or Fisher's exact tests, with Bonferroni correction applied to account for multiple comparisons, and multivariable logistic regression to identify characteristics associated with RCBD.

RESULTS

Among the BD cohort, 9.4% were identified as current RCBD. Compared to NRCBD, RCBD patients had a shorter duration from the first psychiatric consultation to the diagnosis of BD, a reduced duration of their longest period of euthymia, a lower proportion of lifetime hospitalization history due to BD, and less use of electroconvulsive therapy (ECT) within the last 12 months. Additionally, they presented higher baseline scores on the Mood Disorder Questionnaire (MDQ) and the Brief 16-item Quick Inventory of Depressive Symptomatology Self-Report (QIDS-SR16). However, after applying the Bonferroni correction, these differences were not statistically significant. Multivariable logistic regression analysis identified three factors that were independently associated with RCBD: time from first psychiatric consultation to BD diagnosis (Odds Ratio [OR] = 0.512, P = 0.0416), lifetime hospitalization history due to BD (OR = 0.516, P = 0.0476), and ECT treatment within the past 12 months (OR = 0.293, P = 0.0472).

CONCLUSION

This study revealed that the duration from first psychiatric consultation to BD diagnosis, lifetime hospitalization history due to BD, and ECT treatment in the past year were associated with RCBD. Recognizing these factors could contribute to enhance the early identification and clinical outcomes of RCBD. Trial Registration Number Registry ClinicalTrials.gov NCT01770704. Date of Registration: First posted on January 18, 2013.

Role of adjunctive nonpharmacological strategies for treatment of rapid-cycling bipolar disorder

Rapid-cycling bipolar disorder (RCBD) is a phase of bipolar disorder defined by the presence of ≥ 4 mood episodes in a year. It is a common phenomenon characterized by greater severity, a predominance of depression, higher levels of disability, and poorer overall outcomes. It is resistant to treatment by conventional pharmacotherapy. The existing literature underlines the scarcity of evi-dence and the gaps in knowledge about the optimal treatment strategies for RCBD. However, most reviews have considered only pharmacological treatment options for RCBD. Given the treatment-refractory nature of RCBD, nonpharmacological interventions could augment medications but have not been adequately examined. This review carried out an updated and comprehensive search for evidence regarding the role of nonpharmacological therapies as adjuncts to medications in RCBD. We identified 83 reviews and meta-analyses concerning the treatment of RCBD. Additionally, we found 42 reports on adjunctive nonpharmacological treatments in RCBD. Most of the evidence favoured concomitant electroconvulsive therapy as an acute and maintenance treatment. There was pre-liminary evidence to suggest that chronotherapeutic treatments can provide better outcomes when combined with medications. The research on adjunctive psychotherapy was particularly scarce but suggested that psychoeducation, cognitive behavioural therapy, family interventions, and supportive psychotherapy may be helpful. The overall quality of evidence was poor and suffered from several methodological shortcomings. There is a need for more methodologically sound research in this area, although clinicians can use the existing evidence to select and individualize nonpharmacological treatment options for better management of RCBD. Patient summaries are included to highlight some of the issues concerning the implementation of adjunctive nonpharmacological treatments.