ECT in Bipolar Disorder: Data From Russia
Out on PubMed, from investigators in Russia and Germany, is this paper:
Electroconvulsive Therapy (ECT) in Bipolar Disorder Patients with Ultra-Rapid Cycling and Unstable Mixed States.
Medicina (Kaunas). 2021 Jun 15;57(6):624. doi: 10.3390/medicina57060624.PMID: 34203943
The abstract is copied below:
Background and Objectives: Unstable mixed episodes or rapid switching between opposite affective poles within the scope of short cycles was first characterized in 1967 by S. Mentzos as complex polymorphous states with chaotic overlap of manic and depressive symptoms. Well-known examples include antidepressant-induced mania/hypomania and rapid/ultra-rapid/ultradian cycling, when clinicians observe an almost continuous mixed state with a constant change of preponderance of manic or depressive symptoms. Achieving stable remission in these cases is challenging with almost no data on evidence-based treatment. When mood stabilizers are ineffective, electroconvulsive therapy (ECT) has been suggested. Objectives: After reviewing the evidence from available literature, this article presents our own clinical experience of ECT efficacy and tolerability in patients with ultra-rapid cycling bipolar disorder (BD) and unstable mixed states. Materials and Methods: We conducted an open, one-year observational prospective study with a "mirror image" design, including 30 patients with rapid and ultra-rapid cycling BD on long-term mood stabilizer treatment (18 received lithium carbonate, 6 on valproate and 6 on carbamazepine) with limited effectiveness. A bilateral ECT course (5-10 sessions) was prescribed for regaining mood stability. Results: ECT was very effective in 12 patients (40%) with a history of ineffective mood stabilizer treatment who achieved and maintained remission; all of them received lithium except for 1 patient who received carbamazepine and 2 with valproate. Nine patients (30%) showed partial response (one on carbamazepine and two on valproate) and nine patients (30%) had no improvement at all (four on carbamazepine and two on valproate). For the whole sample, the duration of affective episodes was significantly reduced from 36.05 ± 4.32 weeks in the year prior to ECT to 21.74 ± 12.14 weeks in the year post-ECT (p < 0.001). Depressive episodes with mixed and/or catatonic features according to DSM-5 specifiers were associated with a better acute ECT response and/or long-term mood stabilizer treatment outcome after ECT. Conclusions: ECT could be considered as a useful option for getting mood instability under control in rapid and ultra-rapid cycling bipolar patients. Further randomized trials are needed to confirm these results.Keywords: ECT; anticonvulsants; bipolar disorder; catatonia; lithium; mixed states; ultra-rapid cycling.
The pd is here.
And from the text:
The main result of this study is that a single ECT course was able to interrupt URC (ultra-rapid cycling) and mood instability in 40% of BD patients and, what is even more important, modify
or even restore the prophylactic efficacy of a previously ineffective mood stabilizer. This
evidence is especially important for lithium treatment, which is often considered a less
effective agent than anticonvulsants in RC [45,89]. After a single ECT course, lithium
treatment was again very effective in half of patients whose course was previously resistant
to it, and another third of patients showed a partial benefit. The capability of ECT to
improve the efficacy of anticonvulsant mood stabilizers was less evident, acute affective
symptoms improved in only one patient on carbamazepine and two patients on valproate
very much, and another one on carbamazepine and two patients on valproate, respectively,
had a partial prophylactic benefit after a single ECT course. It appears that a period
of stable euthymia, free of affective symptoms, is needed for lithium to be an effective
treatment. The mechanism how ECT restores lithium effectiveness is still speculative.
Possible explanations could be a modulation of the cell membrane ionotropic channel
activity, neurotransmitter turnover, increase in brain-derived neurotrophic factor (BDNF)
production, or a change in blood–brain barrier permeability [90–92]. An important finding
for clinical practice is that a switch from lithium to anticonvulsant appears not always
necessary in treatment-resistant RC. In several of our patients, ECT was sufficient to stop
continuous cycling. We could not locate any literature reporting on a change of long-term
lithium efficacy after a single, three-week ECT course ending continuous mood fluctuations.
This paper adds to the evidence base of the efficacy of ECT for the treatment of severe and treatment-refractory bipolar disorder. It builds upon the work of Italian colleagues, Medda and Perugi. The idea that ECT can restore the efficacy of lithium is intriguing.
The paper has a long section about nuances of diagnosis in bipolar disorder; those interested in such nomenclature/classification will find it mesmerizing.
The inclusion of patient life charts (as per Robert M. Post, see above) is a very nice feature that illustrates the ongoing benefit of ECT well.
It is rare to see an ECT study from Russia; the ECT device described is proprietary; some of the settings are different from those we typically encounter...
All in all, a welcome contribution to the literature; a full read will be ~ 30 minutes.
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