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

Abstract

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.

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

“…However, the evidence is limited and based on either case reports or naturalistic studies with small numbers of patients. These studies are included in Table 1 [ 56 - 72 ].…”

“…Despite these limitations, acute ECT seems to be effective in patients with medication-resistant RCBD with complete or partial remission rates ranging from 70% to 100% in some studies[ 69 , 72 ]. Others have reported lower response rates[ 64 , 66 , 67 , 70 ].…”

“…Others have reported lower response rates[ 64 , 66 , 67 , 70 ]. Nevertheless, sustained periods of remission and better response to mood stabilizers are reported after acute ECT[ 64 , 65 , 67 , 70 , 72 ]. Acute ECT also reduces the number of episodes and the time spent ill.…”

“…ECT is particularly helpful in patients with RCBD who have failed multiple medication trials, those who are intolerant to medication side effects, and those who are at high risk of self-harm[ 3 , 45 , 49 ]. ECT is effective in medication-resistant patients with mania[ 3 , 30 , 47 , 75 , 76 ], depression[ 32 , 41 , 68 , 72 , 75 ], or mixed states[ 49 , 72 ] as a part of RCBD. However, the best response is often obtained in patients with bipolar depression[ 32 , 41 , 67 , 68 , 72 ].…”

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

“…However, this evidence stems mainly from case studies or small-scale research. For instance, an open-label study conducted by Mosolov et al in 2021 on rapid and ultra-rapid cycling BD patients demonstrated a significant reduction in mood episodes following an acute ECT course (Mosolov et al 2021 ). Additionally, a 2011 study by Minnai et al indicated that maintenance ECT substantially reduced the number of morbid days per annum in RCBD patients, highlighting its long-term prophylactic effects (Minnai et al 2011 ).…”