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

Research on clinical aspects of bipolar disorder: A review of Indian studies

Background

Bipolar disorder is one of the severe mental disorders that are associated with significant morbidity of the patients. Despite advancements in our understanding about the disorder, it remains a challenging proposition to treat bipolar disorder, largely since the prophylactic treatment of the disorder requires assessment of complex clinical algorithms. The revisions of the classificatory systems have also changed the conceptualization of the disorder. In this background, we conducted a review of the Indian studies conducted on the clinical aspects of bipolar disorder.

Methods

A narrative review was conducted with focus on the literature published from India. The databases searched included PubMed, Scopus, and Google Scholar, and articles published over the last 15 years by Indian authors were included for this review.

Results

In our review, we could access a substantial volume of research published from India. We could identify studies that catered to most of the relevant themes in bipolar disorder including epidemiology, etiology, comorbidities, stigma, disability, clinical course, cognitive profile, pathways to care, and recovery.

Conclusion

The research trajectory was in line with the research conducted elsewhere in the world. However, certain dissimilarities in terms of focus could also be observed. The possible reason behind this deviation could be the difference in clinical need and unique challenges faced in the management and rehabilitation of patients in bipolar disorder in Indian scenario.

Evaluating the use of electroconvulsive therapy in low-middle income countries: A narrative review

BACKGROUND

Electroconvulsive therapy (ECT) is a well-accepted intervention for treatment-resistant, serious mental illnesses. Its acceptability, efficacy, and tolerability are well documented in high-income settings, but less so in lower- and middle-income countries (LMICs). This report is a narrative review of ECT practice in the latter setting.

METHODS

A literature search was conducted using Medline and PubMed. Initial results yielded 81 publications in English. Following the screening, 19 papers were included to evaluate the information on ECT practice and perceptions.

RESULTS

Reports from LMICs on efficacy, tolerability, and perceptions of ECT were relatively sparse. In general, they confirm its use mostly for treatment-resistant major mental illnesses (i.e., depression, schizophrenia, bipolar disorder). Both modified and unmodified forms of ECT are used and considered equally effective, although the former is better tolerated. Use of unmodified ECT remains significant in LMICs due to its low cost and limited resource requirements. In general, there is satisfaction with ECT and its outcomes. The education of patients and families, content process, and research have been noted as areas to improve.

CONCLUSIONS

ECT is perceived as an effective intervention in LMICs, but use of unmodified ECT remains controversial. There is a need for the development and use of global guidelines to improve clinician training, knowledge sharing with patients and their families, and outcome research.

Electroconvulsive therapy combined with lithium developed reversible pure anomic aphasia: a case report

BACKGROUND

Electroconvulsive therapy (ECT) combined with mood stabilizers is an effective method of treatment for manic episodes; however, there are controversial views on its side effects.

CASE PRESENTATION

A 53-year-old man was diagnosed with bipolar disorder during a manic episode, and had previous conditions such as hypertension, and diabetes. He developed reversible delirium and anomic aphasia during combined treatment with lithium and ECT (Li-ECT). No other neurological symptoms or signs happened during the one-month follow-up period.

CONCLUSIONS

The anomic aphasia appeared after ECT was reversible. Li-ECT should be administered with caution to middle- and older-aged patients with comorbidities, and serum Li levels should be closely monitored during the treatment period.

Combination of lithium and electroconvulsive therapy (ECT) is associated with higher odds of delirium and cognitive problems in a large national sample across the United States

BACKGROUND

Lithium is a helpful adjunct to patients undergoing ECT. However, only case reports and limited data suggest increase risk of delirium. Thus, this continues to be a controversial issue.

OBJECTIVE

In this study, we examine 1) The association and odds of delirium and cognitive problems with ECT and lithium (ECT + Li) combination compared to ECT alone, 2) If positively associated, would this association vary by both type of mood episode and type of disorder?

METHODS

A national sample of 64,728 adult psychiatric inpatients across the US (identified from a total data of about 70 million total discharges annually) was analyzed using linear-by-linear association and logistic regression to assess the odds ratio (OR) for delirium and cognitive impairment for those treated with lithium (N = 158), ECT (N = 64148), or ECT + Li (N = 422) after adjusting for demographics and psychiatric diagnoses.

RESULTS

The prevalence of delirium was higher in the ECT + Lithium group (5.7%) vs. ECT only (0.6%) or lithium only groups (0%). Patients managed with ECT + Lithium have 11.7-fold higher odds (95% CI 7.55-17.99, P < 0.001) of delirium compared to ECT alone. In the ECT + Li group, delirium prevalence was 7.8% in unipolar depression, 3.4% in bipolar depressed, 0% in bipolar mania.

CONCLUSION

These results are surprising given the fading concern about delirium association with ECT + lithium combination. The high odds in the combination group warrant clinical caution, use of lower lithium doses (if combinations cannot be avoided), and vigilance regarding early signs of delirium. These results warrant replication in future studies.

Prediction of electroconvulsive therapy response and remission in major depression: meta-analysis

BACKGROUND

Electroconvulsive therapy (ECT) is considered to be the most effective treatment in severe major depression. The identification of reliable predictors of ECT response could contribute to a more targeted patient selection and consequently increased ECT response rates. Aims To investigate the predictive value of age, depression severity, psychotic and melancholic features for ECT response and remission in major depression.

METHOD

A meta-analysis was conducted according to the PRISMA statement. A literature search identified recent studies that reported on at least one of the potential predictors.

RESULTS

Of the 2193 articles screened, 34 have been included for meta-analysis. Presence of psychotic features is a predictor of ECT remission (odds ratio (OR) = 1.47, P = 0.001) and response (OR = 1.69, P < 0.001), as is older age (standardised mean difference (SMD) = 0.26 for remission and 0.35 for response (P < 0.001)). The severity of depression predicts response (SMD = 0.19, P = 0.001), but not remission. Data on melancholic symptoms were inconclusive.

CONCLUSIONS

ECT is particularly effective in patients with depression with psychotic features and in elderly people with depression. More research on both biological and clinical predictors is needed to further evaluate the position of ECT in treatment protocols for major depression. Declaration of interest None.

Bipolar affective disorder and its impact on various aspects of marital relationship

Bipolar disorder (BD) is a severe mental disorder, which not only has negative consequences on the life of the patient, but also affects the immediate family members. As it often starts early in life, patients who get married often suffer from many negative consequences in their marital life due to the illness. This review focuses on studies which have evaluated marital rates, rate of marital failure, divorce, infertility, and procreation among patients with BD. In addition, this review evaluates the existing literature pertaining to marital adjustment, marital satisfaction, sexual dysfunction, and sexual satisfaction among patients with BD and their partners/spouses. Data suggest that very high proportion of patients with BD get married and marital rates are higher for patients with BD, when compared with those suffering from schizophrenia. In terms of divorce rates, studies suggest that patients with BD have higher rates of divorce. In terms of fertility rates, studies suggest that compared to those without the illness, the fertility rates among patients with BD are lower. In terms of marital adjustment, results are mixed with some studies suggesting poorer marital adjustment among patients and their spouses too. In terms of sexual dysfunction, studies suggest the presence of sexual dysfunction among one-third to half of the patients receiving lithium. To conclude, this review suggests that patients with BD experience multiple negative marital and sexual consequences.

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.

Delirium during the course of electroconvulsive therapy in a patient on lithium carbonate treatment

OBJECTIVE

The safety of concurrent mood stabilizers during the course of electroconvulsive therapy (ECT) is yet to be clearly established. Delirium with concurrent administration of ECT and lithium carbonate is described in this case report.

METHODS

A 30-year-old male with a past history of significant head injury developed delirium during the course of bitemporal ECT.

RESULTS

The clinical picture and the details of the cognitive impairment have been discussed in the report with a focus on relationship between the lithium carbonate administration and the concurrent ECT.

CONCLUSION

Patients with preexisting organic brain damage could be prone to develop the cognitive adverse effect while on a combination of lithium and ECT. Possible interactions between lithium and ECT need further systematic evaluation.

Twenty years of electroconvulsive therapy in a psychiatric unit at a university general hospital

OBJECTIVE

To describe the sociodemographic and clinical profile of patients who underwent electroconvulsive therapy (ECT) at a university general hospital.

METHOD

In this retrospective study, records from all patients undergoing ECT between January 1988 and January 2008 at the psychiatric unit of the general hospital of Universidade Estadual de Campinas (UNICAMP) were reviewed. Telephone contact was made with patients/relatives to collect follow-up data.

RESULTS

A total of 200 charts were reviewed. The majority of patients were women, with a mean age of 39 years, and history of psychiatric hospitalization. The main indications for ECT were depression and catatonia. Complications were observed in less than half of the cases, and most were temporary and not severe. There was a good psychiatric outcome for 89.7% of the patients, especially for catatonic patients (100%, p = 0.02). Thirty-four percent of the cases were later contacted by telephone calls, at a mean of 8.5 years between the procedure and the contact. Among these, three (1.5%) reported persistent memory disorders and 73% considered ECT a good treatment.

CONCLUSION

ECT has been performed according to international guidelines. In the vast majority of cases, undesirable effects were temporary and not severe. Response to ECT was positive in most cases, particularly in catatonic patients.