Efficacy and safety of electroconvulsive therapy in the treatment of bipolar disorder: a systematic review

The Use of ECT in the Elderly-Looking Beyond Depression

PURPOSE OF REVIEW

We reviewed recent evidence on the use of electroconvulsive therapy (ECT) in the geriatric population. This review looked at the literature on depression, for which there is a breadth of data, as well as other conditions that have historically not been as well studied, as well as attempting to provide practical recommendations for ECT practitioners. This review also examined the impact of the COVID-19 pandemic on ECT in the elderly.

RECENT FINDINGS

ECT shows robust efficacy across many psychiatric diseases, from depression and bipolar disorder to psychosis and catatonia. It has also shown positive results at improving behavioral symptoms of dementia, as well as improving motor symptoms seen in Parkinson's disease. It is routinely found to be a safe treatment as well, generally with only minimal transient side effects. ECT should not be considered a "last-resort" treatment for geriatric patients suffering from psychiatric disorders. It has historical and recent literature supporting its use in many psychiatric disorders and has been shown to be safe with minimal side effects when appropriate considerations are taken for the elderly population.

Early electroconvulsive therapy in patients with bipolar depression: A propensity score-matched analysis using a nationwide inpatient database

OBJECTIVES

Electroconvulsive therapy (ECT) is a widely used treatment for bipolar depression; however, evidence of its effectiveness is not sufficient. This study therefore aimed to evaluate whether early ECT is associated with reduced length of hospital stay.

METHODS

In this retrospective cohort study using the Japanese Diagnosis Procedure Combination database, we identified patients admitted for bipolar depression between April 2010 and March 2018. The primary outcome was length of hospital stay, and the secondary outcome was clinical outcomes and total hospitalization costs. Propensity score-matched analyses were performed to compare the outcomes between patients who received ECT within 8 days of admission (early ECT group) and those who did not (control group).

RESULTS

We identified 5941 eligible patients, comprising 219 in the early ECT group and 5722 in the control group. After 1:4 propensity score matching, patients in the early ECT group had significantly shorter lengths of hospital stay than those in the control group (53 days in the early ECT group and 73 days in the control group; difference: -20.2 days; 95 % confidence interval: -29.2 to -11.2 days). There was no significant difference in total hospitalization costs between the two groups. In-hospital mortality and fatal complications were rare in both groups. The result was similar in the sensitivity analysis using inverse probability of treatment weighting.

LIMITATIONS

Our study was limited by retrospective design and the possibility of unmeasured confounders.

CONCLUSIONS

Early ECT was associated with reduced length of hospital stay without increasing total hospitalization costs in patients with bipolar depression.

Bipolar Disorder

Bipolar disorder (BD) affects approximately 2% of U.S. adults and is the most costly mental health condition for commercial insurers nationwide. Rates of BD are elevated among persons with depression, anxiety disorders, and substance use disorders-conditions frequently seen by primary care clinicians. In addition, antidepressants can precipitate manic or hypomanic symptoms or rapid cycling in persons with undiagnosed BD. Thus, screening in these high-risk groups is indicated. Effective treatments exist, and many can be safely and effectively administered by primary care clinicians.

Electroconvulsive Therapy in Psychiatric Disorders: A Narrative Review Exploring Neuroendocrine–Immune Therapeutic Mechanisms and Clinical Implications

Electroconvulsive therapy (ECT) is based on conducting an electrical current through the brain to stimulate it and trigger generalized convulsion activity with therapeutic ends. Due to the efficient use of ECT during the last years, interest in the molecular bases involved in its mechanism of action has increased. Therefore, different hypotheses have emerged. In this context, the goal of this review is to describe the neurobiological, endocrine, and immune mechanisms involved in ECT and to detail its clinical efficacy in different psychiatric pathologies. This is a narrative review in which an extensive literature search was performed on the Scopus, Embase, PubMed, ISI Web of Science, and Google Scholar databases from inception to February 2022. The terms “electroconvulsive therapy”, “neurobiological effects of electroconvulsive therapy”, “molecular mechanisms in electroconvulsive therapy”, and “psychiatric disorders” were among the keywords used in the search. The mechanisms of action of ECT include neurobiological function modifications and endocrine and immune changes that take place after ECT. Among these, the decrease in neural network hyperconnectivity, neuroinflammation reduction, neurogenesis promotion, modulation of different monoaminergic systems, and hypothalamus–hypophysis–adrenal and hypothalamus–hypophysis–thyroid axes normalization have been described. The majority of these elements are physiopathological components and therapeutic targets in different mental illnesses. Likewise, the use of ECT has recently expanded, with evidence of its use for other pathologies, such as Parkinson’s disease psychosis, malignant neuroleptic syndrome, post-traumatic stress disorder, and obsessive–compulsive disorder. In conclusion, there is sufficient evidence to support the efficacy of ECT in the treatment of different psychiatric disorders, potentially through immune, endocrine, and neurobiological systems.

Guidelines for the management of psychosis in the context of mood disorders

Psychotic episodes occur in a substantial proportion of patients suffering from major mood disorders (both unipolar and bipolar) at some point in their lives. The nature of these episodes is less well understood than the more common, non-psychotic periods of illness and hence their management is also less sophisticated. This is a concern because the risk of suicide is particularly high in this subtype of mood disorder and comorbidity is far more common. In some cases psychotic symptoms may be signs of a comorbid illness but the relationship of psychotic mood to other forms of psychosis and in particular its interactions with schizophrenia is poorly understood. Therefore, our targeted review draws upon extant research and our combined experience to provide clinical context and a framework for the management of these disorders in real-world practice - taking into consideration both biological and psychological interventions.

Therapeutic Interventions to Mitigate Mitochondrial Dysfunction and Oxidative Stress–Induced Damage in Patients with Bipolar Disorder

Bipolar disorder (BD) is characterized by mood changes, including recurrent manic, hypomanic, and depressive episodes, which may involve mixed symptoms. Despite the progress in neurobiological research, the pathophysiology of BD has not been extensively described to date. Progress in the understanding of the neurobiology driving BD could help facilitate the discovery of therapeutic targets and biomarkers for its early detection. Oxidative stress (OS), which damages biomolecules and causes mitochondrial and dopamine system dysfunctions, is a persistent finding in patients with BD. Inflammation and immune dysfunction might also play a role in BD pathophysiology. Specific nutrient supplements (nutraceuticals) may target neurobiological pathways suggested to be perturbed in BD, such as inflammation, mitochondrial dysfunction, and OS. Consequently, nutraceuticals may be used in the adjunctive treatment of BD. This paper summarizes the possible roles of OS, mitochondrial dysfunction, and immune system dysregulation in the onset of BD. It then discusses OS-mitigating strategies that may serve as therapeutic interventions for BD. It also analyzes the relationship between diet and BD as well as the use of nutritional interventions in the treatment of BD. In addition, it addresses the use of lithium therapy; novel antipsychotic agents, including clozapine, olanzapine, risperidone, cariprazine, and quetiapine; and anti-inflammatory agents to treat BD. Furthermore, it reviews the efficacy of the most used therapies for BD, such as cognitive–behavioral therapy, bright light therapy, imagery-focused cognitive therapy, and electroconvulsive therapy. A better understanding of the roles of OS, mitochondrial dysfunction, and inflammation in the pathogenesis of bipolar disorder, along with a stronger elucidation of the therapeutic functions of antioxidants, antipsychotics, anti-inflammatory agents, lithium therapy, and light therapies, may lead to improved strategies for the treatment and prevention of bipolar disorder.

Treatment of bipolar disorders in older adults: a review

BACKGROUND

Old age bipolar disorder has been an orphan of psychiatric research for a long time despite the fact that bipolar disorder (BD)-I and II together may affect 0.5-1.0% of the elderly. It is also unclear whether aetiology, course of illness and treatment should differ in patients with a first manifestation in older age and patients suffering from a recurrence of a BD known for decades. This narrative review will summarize the current state of knowledge about the epidemiology, clinical features, and treatment of BD in the elderly.

METHODS

We conducted a Medline literature search from 1970 to 2021 using MeSH terms "Bipolar Disorder" × "Aged" or "Geriatric" or "Elderly". Search results were complemented by additional literature retrieved from examining cross references and by hand search in text books. Varying cut-off ages have been applied to differentiate old age from adult age BD. Within old age BD, there is a reasonable agreement of distinct entities, early and late-onset BD. They differ to some extent in clinical symptoms, course of illness, and some co-morbidities. Point prevalence of BD in older adults appears slightly lower than in working-age adults, with polarity of episodes shifting towards depression. Psychopharmacological treatment needs to take into account the special aspects of somatic gerontology and the age-related change of pharmacokinetic and pharmacodynamic characteristics. The evidence for commonly used treatments such as lithium, mood-stabilizing antiepileptics, antipsychotics, and antidepressants remains sparse. Preliminary results support a role of ECT as well as psychotherapy and psychosocial interventions in old age BD.

CONCLUSIONS

There is an obvious need of further research for all treatment modalities of BD in old age. The focus should be pharmacological and psychosocial approaches, as well as their combination, and the role of physical treatment modalities such as ECT.

Electroconvulsive Therapy for Bipolar Depression in Older Adults

OBJECTIVES

Electroconvulsive therapy (ECT) is a well-established treatment for mood disorders in younger adults and has been consistently shown to be safe and effective in unipolar depression in older adults. However, data on this treatment in older adults with bipolar disorder are limited. In this retrospective study, we report outcomes from all cases of older adults with bipolar depression who received ECT from a large academic institution over a 7-year period.

METHODS

We retrospectively identified all patients 65 years and older with bipolar depression who were treated with ECT over a 7-year period. Patients receiving ECT for an episode of bipolar depression were included in the study based on chart review and availability of documented outcome measures. Primary outcomes were changes in Montreal Cognitive Assessment and Clinical Global Impressions scores.

RESULTS

We identified 34 patients meeting inclusion criteria. Collectively, patients had statistically significant improvement in Montreal Cognitive Assessment scores and reductions in Clinical Global Impressions severity scores after treatment. Pre- and posttreatment Montgomery-Asberg Depression Rating Scale scores were also available for a subset of 20 patients and demonstrated a similarly significant reduction in severity with treatment. There were no serious adverse effects of treatment, and no patients discontinued treatment.

CONCLUSIONS

Electroconvulsive therapy was well tolerated and effective in treating bipolar depression in older adults. Importantly, these findings challenge commonly held worries about cognitive decline in older adults receiving ECT. It should be a regular consideration for management of this challenging illness in a population that may otherwise not respond to pharmacotherapy.

Old Age Bipolar Disorder-Epidemiology, Aetiology and Treatment

Data regarding older age bipolar disorder (OABD) are sparse. Two major groups are classified as patients with first occurrence of mania in old age, the so called “late onset” patients (LOBD), and the elder patients with a long-standing clinical history, the so called “early onset” patients (EOBD). The aim of the present literature review is to provide more information on specific issues concerning OABD, such as epidemiology, aetiology and treatments outcomes. We conducted a Medline literature search from 1970–2021 using the MeSH terms “bipolar disorder” and “aged” or “geriatric” or “elderly”. The additional literature was retrieved by examining cross references and by a hand search in textbooks. With sparse data on the treatment of OABD, current guidelines concluded that first-line treatment of OABD should be similar to that for working-age bipolar disorder, with specific attention to side effects, somatic comorbidities and specific risks of OABD. With constant monitoring and awareness of the possible toxic drug interactions, lithium is a safe drug for OABD patients, both in mania and maintenance. Lamotrigine and lurasidone could be considered in bipolar depression. Mood stabilizers, rather than second generation antipsychotics, are the treatment of choice for maintenance. If medication fails, electroconvulsive therapy is recommended for mania, mixed states and depression, and can also be offered for continuation and maintenance treatment. Preliminary results also support a role of psychotherapy and psychosocial interventions in old age BD. The recommended treatments for OABD include lithium and antiepileptics such as valproic acid and lamotrigine, and lurasidone for bipolar depression, although the evidence is still weak. Combined psychosocial and pharmacological treatments also appear to be a treatment of choice for OABD. More research is needed on the optimal pharmacological and psychosocial approaches to OABD, as well as their combination and ranking in an evidence-based therapy algorithm.

The CINP Guidelines on the Definition and Evidence-Based Interventions for Treatment-Resistant Bipolar Disorder

BACKGROUND

Resistant bipolar disorder is a major mental health problem related to significant disability and overall cost. The aim of the current study was to perform a systematic review of the literature concerning (1) the definition of treatment resistance in bipolar disorder, (2) its clinical and (3) neurobiological correlates, and (4) the evidence-based treatment options for treatment-resistant bipolar disorder and for eventually developing guidelines for the treatment of this condition.

MATERIALS AND METHODS

The PRISMA method was used to identify all published papers relevant to the definition of treatment resistance in bipolar disorder and the associated evidence-based treatment options. The MEDLINE was searched to April 22, 2018.

RESULTS

Criteria were developed for the identification of resistance in bipolar disorder concerning all phases. The search of the literature identified all published studies concerning treatment options. The data were classified according to strength, and separate guidelines regarding resistant acute mania, acute bipolar depression, and the maintenance phase were developed.

DISCUSSION

The definition of resistance in bipolar disorder is by itself difficult due to the complexity of the clinical picture, course, and treatment options. The current guidelines are the first, to our knowledge, developed specifically for the treatment of resistant bipolar disorder patients, and they also include an operationalized definition of treatment resistance. They were based on a thorough and deep search of the literature and utilize as much as possible an evidence-based approach.

Prescribing practices of Indian psychiatrists in the treatment of bipolar disorder

OBJECTIVE

The treatment of bipolar disorder is challenging because of its clinical complexity and availability of multiple treatment options, none of which are ideal mood stabilizers. This survey studies prescription practices of psychiatrists in India and their adherence to guidelines.

METHOD

In total, 500 psychiatrists randomly selected from the Indian Psychiatric Society membership directory were administered a face-to-face 22-item questionnaire pertaining to the management of bipolar disorder.

RESULTS

For acute mania, most practitioners preferred a combination of a mood stabilizer and an atypical antipsychotic to monotherapy. For acute depression, there was a preference for a combination of an antidepressant and a mood stabilizer over other alternatives. Electroconvulsive therapy was preferred in the treatment of severe episodes and to hasten the process of recovery. Approximately, 50% of psychiatrists prescribe maintenance treatment after the first bipolar episode, but maintenance therapy was rarely offered lifelong. While the majority (85%) of psychiatrists acknowledged referring to various clinical guidelines, their ultimate choice of treatment was also significantly determined by personal experience and reference to textbooks.

LIMITATIONS

The study did not study actual prescriptions. Hence, the responses to queries in the survey are indirect measures from which we have tried to understand the actual practices, and of course, these are susceptible to self-report and social-desirability biases. This was a cross-sectional study; therefore, temporal changes in responses could not be considered.

CONCLUSION

Overall, Indian psychiatrists seemed to broadly adhere to recommendations of clinical practice guidelines, but with some notable exceptions. The preference for antidepressants in treating depression is contrary to general restraint recommended by most guidelines. Therefore, the efficacy of antidepressants in treating bipolar depression in the context of Indian psychiatrists' practice needs to be studied systematically. Not initiating maintenance treatment early in the course of illness may have serious implications on the long-term outcome of bipolar disorder.

Management of a complex patient - intravenous olanzapine use

OBJECTIVE:

This case report aims to highlight the challenges faced by mental health clinicians in managing complex medical and psychiatric presentation, with a particular interest in intravenous (IV) olanzapine use outside the emergency department (ED) and intensive care unit setting.

CONCLUSION:

There is no current prescribing guideline regarding the use of IV olanzapine for acute agitation associated with schizophrenia and bipolar disorder. Most of the literature available regarding the use of IV olanzapine has originated from studies performed in the ED setting, with the majority of studies reporting a favourable efficacy and safety profile for IV olanzapine. Further research on the utilization of IV olanzapine in the general medical ward is required. Until more data is available, use of IV olanzapine in the acute arousal setting on a general medical ward remains off-label.

Right unilateral electroconvulsive therapy does not cause more cognitive impairment than pharmacologic treatment in treatment-resistant bipolar depression: A 6-month randomized controlled trial follow-up study

OBJECTIVES

Electroconvulsive therapy is an effective treatment for bipolar depression, but there are concerns about whether it causes long-term neurocognitive impairment.

METHODS

In this multicenter randomized controlled trial, in-patients with treatment-resistant bipolar depression were randomized to either algorithm-based pharmacologic treatment or right unilateral electroconvulsive therapy. After the 6-week treatment period, all of the patients received maintenance pharmacotherapy as recommended by their clinician guided by a relevant treatment algorithm. Patients were assessed at baseline and at 6 months. Neurocognitive functions were assessed using the Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) Consensus Cognitive Battery, and autobiographical memory consistency was assessed using the Autobiographical Memory Interview-Short Form.

RESULTS

Seventy-three patients entered the trial, of whom 51 and 26 completed neurocognitive assessments at baseline and 6 months, respectively. The MATRICS Consensus Cognitive Battery composite score improved by 4.1 points in both groups (P = .042) from baseline to 6 months (from 40.8 to 44.9 and from 41.9 to 46.0 in the algorithm-based pharmacologic treatment and electroconvulsive therapy groups, respectively). The Autobiographical Memory Interview-Short Form consistency scores were reduced in both groups (72.3% vs 64.3% in the algorithm-based pharmacologic treatment and electroconvulsive therapy groups, respectively; P = .085).

CONCLUSIONS

This study did not find that right unilateral electroconvulsive therapy caused long-term impairment in neurocognitive functions compared to algorithm-based pharmacologic treatment in bipolar depression as measured using standard neuropsychological tests, but due to the low number of patients in the study the results should be interpreted with caution.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00664976.

Superior anti-suicidal effects of electroconvulsive therapy in unipolar disorder and bipolar depression

OBJECTIVES

Electroconvulsive therapy (ECT) has long been believed to reduce suicidal tendencies in patients with affective disorders; however, ECT recipients, who constitute the most severely ill and suicidal patients, are not eligible to participate in head-to-head randomized controlled trials. Large-scale studies are required to investigate the anti-suicidal effects of ECT vs psychopharmacotherapy.

METHODS

A nationwide retrospective cohort study design was used. Data were obtained from the Taiwan National Health Insurance Research Database. Inpatients with unipolar disorder or bipolar disorder who received ECT (n = 487) were observed from 1 January 2000 to 31 December 2013 for suicide events. The non-ECT control cohort consisted of inpatients with psychopharmacotherapy randomly matched (ratio, 1:4) by age, sex, and diagnosis.

RESULTS

After potential confounds had been accounted for, the adjusted hazard ratio (HR) was 0.803, indicating that ECT recipients showed a 19.7% lower risk of suicide than control individuals. The stratum-specific adjusted HR was 0.79 in patients with unipolar disorder (P = .041) and 0.923 in patients with bipolar disorder (P = .254). Upon further stratification of the patients with bipolar disorder by their affective states, the adjusted HR was 0.805 (P = .046) for bipolar depression, 1.048 for bipolar mania (P = .538), and 0.976 for mixed bipolar state (P = .126).

CONCLUSIONS

Compared with psychopharmacotherapy, ECT exerted superior anti-suicidal effects in patients with unipolar disorder and bipolar depression; however, there was a lack of superior anti-suicidal effects of ECT in the treatment of patients with bipolar mania and mixed state.

Speed of antidepressant response to electroconvulsive therapy in bipolar disorder vs. major depressive disorder

AIMS

We reviewed studies that reported speed of antidepressant response to electroconvulsive therapy (ECT) in both bipolar depression (BPD) and major depressive disorder (MDD).

METHODS

We identified English language reports allowing this comparison.

RESULTS

Ten studies met our criteria. Four reported significantly faster response in BPD and in one there was trend for faster response. None reported evidence for slower response in BPD.

CONCLUSION

The findings support further study of speed of response to ECT in BPD.

Correlates of self-reported, autobiographical, and mini-mental status examination defined memory deficits following electroconvulsive therapy in South India

BACKGROUND

Cognitive deficits, self-reported or found following electroconvulsive therapy (ECT), and their correlates are diverse. Despite the characteristics of people receiving ECT in Asia differ widely from the west, pertinent research from Asia remains sparse.

METHODS

We investigated the correlates of self-reported, mini-mental status examination (MMSE) defined, and autobiographical memory deficits in a cohort that received ECT in a south Indian tertiary-care setting. 76 consecutive consenting people were recruited within seven days of completing their ECT course. Memory was assessed by a subjective Likert scale, MMSE, and an autobiographical memory scale (AMS). Psychopathology was assessed by brief psychiatric rating scale, and serum cortisol levels were estimated by chemi-luminescence immunoassays. Relevant sociodemographic and clinical data were collected from the participants, and their medical records. The correlates were analysed using generalised linear models after adjusting for the effects of potential confounders.

RESULTS

Self-reported, MMSE-defined, and autobiographical memory deficits were present in 27.6% (95%CI 17.6-37.7%), 42.1% (95%CI 31.0-53.2%), and 36.8% (95%CI 26.0-47.7%) of participants, respectively. Agreement between the memory deficits was poor. Age, less education, duration of illness, hypothyroidism, and past history of another ECT course were significantly associated with MMSE-defined deficits. Age, anaemia, past ECT course, and pre-ECT blood pressure were significantly associated with autobiographical memory deficits, while residual psychopathology and cortisol levels were significantly associated with self-reported memory deficits.

CONCLUSION

Self-reported, MMSE-defined, and autobiographical memory deficits are common at the completion of ECT course, and their correlates differ. All service users receiving ECT need periodic cognitive assessments evaluating multiple cognitive domains.

Ultrabrief Electroconvulsive Therapy for Manic Episodes of Bipolar Disorder

Right unilateral ultrabrief-pulse electroconvulsive therapy (RUL-UB ECT) is gaining popularity and is being used for the treatment of severe major depression. Though brief pulse-width ECT has shown to have robust antimanic effects, the efficacy of UB ECT for mania has not been studied, and there are very few reports on its use in mania. A brief case series of 3 patients with manic episode of bipolar disorder who were treated with RUL-UB ECT is presented here. The successful treatment of 2 patients in this report suggests that some manic episodes can be rapidly and effectively treated with RUL-UB ECT.

Brain stimulation treatments in bipolar disorder: A review of the current literature

OBJECTIVES

Brain stimulation techniques are non-pharmacologic strategies which offer additional therapeutic options for treatment-resistant depression (TRD). The purpose of this paper is to review the current literature regarding the use of brain stimulation in resistant bipolar disorder (BD), with particular reference to hypomanic/manic symptoms.

METHODS

Keywords pertaining to the brain simulation techniques used in the treatment of depression (either unipolar or bipolar) along with their role in regard to hypomanic/manic symptoms were used to conduct an electronic search of the literature. Pertinent findings were identified by the authors and reviewed.

RESULTS

Brain stimulation techniques represent a valid therapeutic option in TRD. They have been extensively studied in unipolar depression and, to a minor extent, in the depressive phase of BD, showing encouraging but often limited results. With exception of electroconvulsive therapy, the efficacy of brain stimulation in the treatment of manic symptoms of bipolar patients is still uncertain and needs to be fully evaluated.

CONCLUSIONS

Brain stimulation in BD is derived from its use in unipolar depression. However, there are many important differences between these two disorders and more studies with a systematic approach need to be conducted on larger samples of bipolar patients with treatment-resistant characteristics.

Levels of mania and cognitive performance two years after ECT in patients with bipolar I disorder - results from a follow-up study

BACKGROUND

There is limited evidence on the long-term outcomes for patients with bipolar I disorder (BP-I-D) and treated with ECT. Therefore, we asked whether mania scores and cognitive performance at the end of ECT treatment (baseline/BL) predicted mania scores, cognitive performance, recurrence, treatment adherence, and mood (depression; hypomania) two years later (follow-up/FU).

METHOD

38 patients with BP-I-D undergoing ECT at baseline were followed up two years later. A brief psychiatric and cognitive assessment (Mini Mental State Examination; short-term verbal memory test) was performed; patients completed questionnaires covering recurrence, treatment adherence, and mood (depression; hypomania).

RESULTS

High cognitive performance at BL predicted high cognitive performance at FU; low mania scores at BL predicted low mania scores at FU. By FU, cognitive performance had increased and mania scores decreased. Mania scores and cognitive performance at BL did not predict recurrence, or adherence to medication, or mood (depression; hypomania).

CONCLUSIONS

The pattern of results suggests that after two years of successful treatment of acute mania with ECT, cognitive impairment, measured by MMSE and a short-term verbal memory test, is not impaired and mood symptom recurrence seems to be improved. Mania scores and cognitive performance at the end of ECT treatment predicted neither mood (depression; hypomania), nor recurrence, or adherence to medication two years later.

Treatment of Super-Refractory Status Epilepticus

Super-refractory status epilepticus (SRSE) is a devastating neurological condition with limited treatment options. We conducted an extensive literature search to identify and summarize the therapeutic options for SRSE. The search mainly resulted in case reports of various pharmacologic and non-pharmacologic treatments. The success rate of each of the following agents, ketamine, inhaled anesthetics, intravenous immunoglobulin G (IVIG), IV steroids, ketogenic diet, hypothermia, electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), and vagal nerve stimulation (VNS), are discussed in greater detail. The choice of appropriate treatment options for a given patient is based on clinical presentation. This review focuses on evidence-based, pharmacotherapeutic strategies for patients in SRSE.

What happens to the course of bipolar disorder after electroconvulsive therapy?

BACKGROUND

Bipolar disorder (BD) encompasses manic and depressive episodes and an illness-free interval. Treatments used in BD patients may influence the ill phases with different actions on the illness-free interval.

METHODS

We performed a naturalistic mirror-image retrospective study analyzing the number of episodes and admissions in 41 BD patients for the same period of time of 5 years before and after electroconvulsive therapy (ECT). Furthermore, we assessed the duration of free intervals before and after ECT as a sign of prolonged well-being. Univariate analysis with t-test was used to compare differences before and after ECT, while analysis of variance was used to compare factors possibly associated with the efficacy on free-interval of ECT.

RESULTS

Comparing the 5-year periods before and after ECT, we found significantly longer [13.2 ± 9.0 months before ECT to 25.1 ± 19.1 after treatment (t=3.8; p<0.0001)] free intervals, as well as significant reductions in the number of episodes [5.9 ± 3.0 before ECT to 1.0 ± 1.7 after treatment (t=9.3; p<0.0001)], and in the number of admissions [2.2 ± 1.3 before ECT to 0.2 ± 0.5 after treatment (t=9.4; p<0.0001)].

LIMITATIONS

The main limitations of this study consisted in the relatively small sample size, the mirror-image retrospective naturalistic study design and possibly patient selection bias.

CONCLUSIONS

Electroconvulsive therapy seemed to increase free-intervals and reduced number of BD episodes and admissions. It is plausible that ECT, along with suspending antidepressant treatment, might carry intrinsic stabilizing effect on the course of BD.

Early effects of modern electroconvulsive therapy on subjective memory in patients with mania or depression

CONTEXT

Although electroconvulsive therapy (ECT) is considered a very effective tool for the treatment of psychiatric diseases, memory disturbances are among the most important adverse effects.

AIMS

This study aimed to assess prospectively early subjective memory complaints in depressive and manic patients due to bilateral, brief-pulse ECT, at different stages of the treatment, compare the associations between psychiatric diagnosis, sociodemographic characteristics, and ECT characteristics.

SETTINGS AND DESIGN

This prospective study was done with patients undergoing ECT between November 2008 and April 2009 at a tertiary care psychiatry hospital of 2000 beds.

MATERIALS AND METHODS

A total of 140 patients, scheduled for ECT with a diagnosis of bipolar disorder (depressive or manic episode) or unipolar depression according to Diagnostic and Statistical Manual of Mental Disorders IV diagnostic criteria, were included in the study and invited to complete the Squire Subjective Memory Questionnaire (SSMQ) before ECT, after the first and third sessions and end of ECT treatment.

STATISTICAL ANALYSIS

Mean values were compared with the Kruskal-Wallis test and comparison of the longitudinal data was performed with a nonparametric longitudinal data analysis method, F1_LD_F1 design.

RESULTS

SSMQ scores of the patients before ECT were zero. SSMQ scores showed a decrease after the first and third ECT sessions and before discharge, showing a memory disturbance after ECT and were significantly less severe in patients with mania in comparison to those with depression.

CONCLUSIONS

These findings suggest an increasing degree of subjective memory complaints with bilateral brief-pulse ECT parallel to the increasing number of ECT sessions.

Efficacy of Electroconvulsive Therapy in Bipolar Disorder with Mixed Features

Introduction. Mixed states represent a frequent presentation of bipolar disorder, associated with higher resistance to psychopharmacology. Limited evidence supports the use of ECT in these patients. We aim to report our experience on treating bipolar mixed states with ECT. Methods. Retrospective data were collected from all bipolar patients submitted to acute ECT treatment, between June 2006 and June 2011. Three groups were created in terms of affective polarity of the episode. CGI rating was used to establish clinical remission and demographic and clinical variables were compared among groups. Long-term outcome was assessed through readmission measures, considering the use of continuation or maintenance ECT. Results. During the study time frame, a total of 50 ECT course treatments were performed on 41 bipolar patients. All affective episodes, except one mixed state, showed a positive clinical response. Patients with mixed state presentation tended to be younger and have an earlier first hospitalization than depressed patients. No differences were found in terms of ECT sessions performed, length of hospital admission, referral to continuation ECT treatment, number of readmissions, and time until next readmission. Conclusions. Our results support the effectiveness of ECT in patients experiencing a mixed affective state.

Autism-Like Behavior in BTBR Mice Is Improved by Electroconvulsive Therapy

Autism is a developmental disorder characterized by impairments in social and communication abilities, as well as by restricted and repetitive behaviors. Incidence of autism is higher than earlier estimates, and treatments have limited efficacy and are costly. Limited clinical and experimental evidence suggest that patients with autism may benefit from electroconvulsive therapy (ECT). We examined the therapeutic potential of ECT in BTBR T+ tf/j mice, which represent a validated model of autism. A series of 13 electroconvulsive shocks (ECS) delivered twice a day over 7 days reversed core autism-like behavioral abnormalities-impaired sociability, social novelty, and repetitive behavior-when the animals were tested 24 h after the last ECS. The effect lasted up to 2 weeks after ECT. Neither single ECS nor a series of 6 ECS modified animals' behavior. Chronic infusion into the lateral brain ventricle of a preferential oxytocin receptor blocker (2S)-2-Amino-N-[(1S,2S,4R)-7,7-dimethyl-1-[[[4-(2-methylphenyl)-1-piperazinyl]sulfonyl]methyl]bicyclo[2.2.1]hept-2-yl]-4-(methylsulfonyl)butanamide hydrochloride abolished ECT-induced improvement of sociability and mitigated improvement of social novelty but did not affect ECT-induced reversal of repetitive behavior. These proof-of-principle experiments suggest that ECT may, indeed, be useful in the treatment of autism, and that its therapeutic effects may be mediated, in part, by central oxytocin signaling.

Excess mortality in bipolar disorders

Bipolar disorder is associated with high mortality, and people with this disorder on average may die 10-20 years earlier than the general population. This excess and premature mortality continues to occur despite a large and expanding selection of treatment options dating back to lithium and now including anticonvulsants, antipsychotics, and evidence-based psychotherapies. This review summarizes recent findings on mortality in bipolar disorder, with an emphasis on the role of suicide (accounting for about 15% of deaths in this population) and cardiovascular disease (accounting for about 35-40% of deaths). Recent care models and treatments incorporating active outreach, integrated mental and physical health care, and an emphasis on patient self-management have shown promise in reducing excess mortality in this population.

The psychopharmacology algorithm project at the Harvard South Shore Program: an algorithm for acute mania

This new algorithm for the pharmacotherapy of acute mania was developed by the Psychopharmacology Algorithm Project at the Harvard South Shore Program. The authors conducted a literature search in PubMed and reviewed key studies, other algorithms and guidelines, and their references. Treatments were prioritized considering three main considerations: (1) effectiveness in treating the current episode, (2) preventing potential relapses to depression, and (3) minimizing side effects over the short and long term. The algorithm presupposes that clinicians have made an accurate diagnosis, decided how to manage contributing medical causes (including substance misuse), discontinued antidepressants, and considered the patient's childbearing potential. We propose different algorithms for mixed and nonmixed mania. Patients with mixed mania may be treated first with a second-generation antipsychotic, of which the first choice is quetiapine because of its greater efficacy for depressive symptoms and episodes in bipolar disorder. Valproate and then either lithium or carbamazepine may be added. For nonmixed mania, lithium is the first-line recommendation. A second-generation antipsychotic can be added. Again, quetiapine is favored, but if quetiapine is unacceptable, risperidone is the next choice. Olanzapine is not considered a first-line treatment due to its long-term side effects, but it could be second-line. If the patient, whether mixed or nonmixed, is still refractory to the above medications, then depending on what has already been tried, consider carbamazepine, haloperidol, olanzapine, risperidone, and valproate first tier; aripiprazole, asenapine, and ziprasidone second tier; and clozapine third tier (because of its weaker evidence base and greater side effects). Electroconvulsive therapy may be considered at any point in the algorithm if the patient has a history of positive response or is intolerant of medications.

Stigma and bipolar disorder: a review of the literature

BACKGROUND

Psychiatric stigma is pervasive injustice that complicates the course of illness and reduces quality of life for people with mental illnesses. This article reviews the research examining stigma towards bipolar disorder (BD) with a view to guiding the development of stigma reduction initiatives and ongoing research.

METHODS

PsychInfo, Medline, and Embase databases were searched for peer-reviewed studies addressing stigma in BD.

RESULTS

Stigma is a serious concern for individuals with BD and their families. Stigma occurs within affected individuals, families, social environments, work and school environments, and the healthcare industry. With stigma often come a loss of social support and occupational success, reduced functioning, higher symptom levels and lower quality of life. BD stigma is comparable to that of other severe mental illnesses, such as schizophrenia. Few interventions are available to specifically target stigma against BD.

LIMITATIONS

Most studies have used explicit, attitude-based measures of stigma without controlling for social desirability, which may not translate into real-world stigmatizing behaviors. Furthermore, many studies have not clearly delineated results in a manner consistent with the conceptual framework of stigmatization.

CONCLUSIONS

Stigma toward BD is ubiquitous and has insidious consequences for affected individuals and their families. Stigma reduction initiatives should target individuals living with BD, their families, workplaces, and the healthcare industry, taking into account the experiences and impacts of BD stigma to improve social support, course of illness, and quality of life.

A review of potassium channels in bipolar disorder

Although bipolar disorder (BP) is one of the most heritable psychiatric conditions, susceptibility genes for the disorder have yet to be conclusively identified. It is likely that variants in multiple genes across multiple pathways contribute to the genotype–phenotype relationship in the affected population. Recent evidence from genome-wide association studies implicates an entire class of genes related to the structure and regulation of ion channels, suggesting that the etiology of BP may arise from channelopathies. In this review, we examine the evidence for this hypothesis, with a focus on the potential role of voltage-gated potassium channels. We consider evidence from genetic and expression studies, and discuss the potential underlying biology. We consider animal models and treatment implications of the involvement of potassium ion channelopathy in BP. Finally, we explore intriguing parallels between BP and epilepsy, the signature channelopathy of the central nervous system.

Assessment of cognitive impairments and seizure characteristics in electroconvulsive therapy with and without sodium valproate in manic patients

OBJECTIVES

The aim of the present study was two-fold: (1) to compare, in a controlled double-blind quasi-randomized clinical trial, treatment improvements, treatment outcome, and cognitive impairments in patients suffering from current manic episodes, while treated with electroconvulsive therapy (ECT) with and without concurrent sodium valproate therapy, and (2) to compare ECT seizure characteristics in patients with and without concurrent sodium valproate therapy.

METHODS

A total of 40 inpatients (mean age = 31.80 years, SD = 8.06; 75% males) suffering from bipolar disorders and currently in a manic state took part in the study. They were quasi-randomly assigned either to the target (continuation of sodium valproate administration) or to the control group (discontinuation of sodium valproate administration). All patients underwent bifrontal ECT for at least 6 sessions. Improvements and cognitive impairments were assessed, and seizure characteristics (duration, threshold) were also recorded.

RESULTS

Manic episodes improved significantly over time, and irrespective of the group (target vs. control group). Cognitive impairments did not alter over time or between groups. Seizure duration did not change over time or between groups. Seizure threshold did not change over time, but was lower in the target than in the control group.

CONCLUSIONS

Continuing the administration of sodium valproate neither adversely affects, nor enhances cognitive impairments or seizure duration, but reduces seizure threshold during ECT in patients suffering from manic episodes. Moreover, gender appeared to be more strongly associated with cognitive impairment and seizure activity than treatment approaches in these psychiatric conditions.

Clinical profile and outcome of bipolar disorder patients receiving electroconvulsive therapy: a study from north India

BACKGROUND

Although electroconvulsive therapy (ECT) is used quite frequently among the bipolar patients in developing countries, very little data are available with regard to its effectiveness from the developing countries.

AIM

A retrospective case note review was carried out of bipolar disorder patients who were given ECT.

MATERIALS AND METHODS

Details of demographic and clinical profile, indications for ECT, response patterns, adverse effects, etc. were recorded.

RESULTS

Among all the patients who received ECT, 18% were diagnosed to have bipolar disorder. ECT was administered most commonly for mania with psychotic symptoms, followed by severe depression with psychotic symptoms. Comorbid physical problems were seen in many patients. Nearly 90% of patients in both the subgroups showed more than 50% response (based on reduction in the standardized rating scales) with ECT. Few patients (22%) reported some kind of side effects.

CONCLUSIONS

ECT is useful in the management of acute phase of mania and depression.