Patients With Refractory Bipolar Depression May Benefit From ECT
Electroconvulsive therapy (ECT) is equally effective for bipolar depression and unipolar major depression, experts say.
Nearly two decades ago, APA published clinical practice guidelines on bipolar disorder, noting that there was substantial evidence to support the use of electroconvulsive therapy (ECT) for patients with severe, treatment-resistant bipolar depression. Since then, the clinical evidence in support of ECT for bipolar disorder has continued to grow.
When considering ECT for a patient with refractory depression, do not focus on polarity but instead on disease severity and accompanying symptoms such as delusions, notes Charles Kellner, M.D.
David Hathcox
“Yet to this day, many people still dismiss ECT when discussing bipolar disorder treatment options, despite the many studies showing its effectiveness,” said Charles Kellner, M.D., an adjunct professor of psychiatry at the Medical University of South Carolina and a leading expert on the use of ECT for treating mood disorders. “In fact, patients with bipolar depression on average respond with fewer treatment sessions [than those with unipolar depression].”
Kellner noted that multiple recent journal review articles have failed to mention ECT when describing evidence-based treatment options for patients with bipolar disorder. He praised a comprehensive review published this year in the New England Journal of Medicine for referencing the effectiveness of ECT for treating acute and long-term symptoms of bipolar disorder, but even in this case, the discussion of ECT was relegated to a few short sentences.
Why aren’t more people talking about the potential benefits of ECT for patients with bipolar disorder? Kellner thinks that some psychiatrists see major depressive disorder and bipolar disorder as so distinctly different that they assume the procedures or criteria for ECT must be different if a patient has bipolar depression rather than unipolar depression.
“But polarity of the mood disorder makes no difference in determining who is a good candidate for ECT,” he continued. Better clues for determining patients most likely to benefit from the therapy include those with very severe depression, delusions, suicidal behaviors, or catatonic symptoms, he noted.
Though ECT poses legitimate risks like delirium and cognitive problems, Christopher Abbott, M.D., says that post-ECT mania in depressed bipolar patients is rare and likely not directly caused by the electrical stimulation.
Psychiatrists should consider ECT for patients experiencing particularly serious symptoms, said Christopher Abbott, M.D., an associate professor of psychiatry at the University of New Mexico who studies ECT in bipolar patients. “If you see a patient with severe bipolar depression who is not eating and losing weight, then ECT should come up in the conversation sooner than later.”
Managing ECT Side Effects
Treating bipolar patients with ECT may require tapering some medications prior to the therapy and closely tracking the patients for emerging symptoms of mania after ECT, Abbott explained.
ECT works by applying electricity to the brain to stimulate brief seizures. Because anticonvulsants (commonly prescribed to patients with bipolar disorder) can make it harder to induce these seizures, safely tapering the medications prior to the procedure is recommended. This helps ensure the minimum effective electrical charge is used, minimizing cognitive side effects from ECT, Abbott said. He added that lithium—though not an anticonvulsant—should also be discontinued prior to an ECT procedure since there is evidence that patients receiving ECT while taking lithium have an increased risk of delirium and transient cognitive impairment.
AJP Review Examines Evidence Supporting ECT for Mania
While there is less clinical evidence supporting the use of ECT for mania compared with bipolar depression, studies over the past three decades suggest ECT can also lead to symptom improvements in patients with mania and related syndromes. ECT expert Harold Sackiem, Ph.D., of Columbia University along with Alby Elias, M.D., and Naveen Thomas, M.D., of the University of Melbourne presented key takeaways from these trials in a recent review in AJP in Advance.
“ECT is one of the few interventions in psychiatry with established efficacy in treating both depressive and manic syndromes,” Sackiem and colleagues wrote. Still, the authors acknowledged many questions remain, including how frequently ECT should be administered to patients with mania, the best placement of electrodes, and whether patients should continue taking anticonvulsant medications and/or lithium during an ECT course. There are also ethical challenges that may arise when considering ECT for patients with mania, who the authors noted are more likely than those with depression to experience “severe impairment of judgment and insight, and catatonic or delirious presentation.”
They added, “Stigma, logistics, and ethical factors constrain ECT administration in this condition and lead to its underutilization. However, the past three decades have produced promising research regarding the use of ECT in mania.”
“Electroconvulsive Therapy in Mania: A Review of 80 Years of Clinical Experience” is posted here.
“There is clear evidence that bipolar patients in remission are more likely to have lingering cognitive impairments compared with remitted unipolar patients, so it is a researchable question as to whether ECT would affect cognition differentially in these two disorders,” Peter Rosenquist, M.D., a professor and the Leon Henri Charbonnier Endowed Chair of Psychiatry at the Medical College of Georgia, told Psychiatric News. The current data, however, suggest there are no differences in the risk of short-term cognitive issues between unipolar or bipolar patients following ECT.
Case reports have also shown that some patients with bipolar depression experienced emergent mania following an ECT procedure, but there is no strong evidence to infer that ECT causes the mania, Abbott continued.
“As a field, mood disorder researchers need to address the stigma surrounding [ECT, including] cognitive side effects like delirium and brief memory loss,” Abbott said. These are legitimate concerns that doctors should address with patients, but their impact remains exaggerated in the public eye.
ECT Research Continues
In addition to improving awareness about the effectiveness of ECT for patients with bipolar disorder, continued research is needed to make ECT a more precise treatment, Abbott continued. He is currently using brain imaging techniques to pinpoint activity changes in brain circuit networks following ECT, which he said may one day reveal the optimal places to place ECT electrodes and focus the stimulation.
Another area of research interest is developing better ways to predict the patients with bipolar disorder who are most likely to benefit from ECT. Giulio Perugi, M.D., and his colleagues at the University of Pisa in Italy have been following a cohort of several hundred patients with bipolar depression who received ECT for years to assess their recovery and what factors might be predictors of that recovery.
In an analysis published this year, Perugi and colleagues identified several traits in patients with bipolar depression that appeared to signal a better response to ECT. Perugi’s team found that patients with delusions of guilt were much more likely to respond to ECT than those with other types of delusions, such as paranoia. They also found that patients with strong mixed features (symptoms of depression and mania) were more likely to benefit from ECT than those with pure depression or minor mania symptoms.
Kellner lauded this important work at characterizing bipolar response to ECT, but also emphasized that 72% of the bipolar patients in the study showed meaningful improvements in depression symptoms.
“This rate is vastly more impressive than any other strategy that has been discussed for treatment-resistant bipolar depression,” Kellner said. He hopes that more of his colleagues will consider discussing ECT with patients who have bipolar disorder and do not respond to first-line interventions, and not put off this option in favor of less evidence-based approaches that may leave patients in a depressed state longer than they need to be.
“Most of my colleagues have seen firsthand how rapidly bipolar depression can resolve with ECT and are glad to accept help from our team,” Rosenquist said. “We provide ECT to some of the most severe and persistently ill inpatients in the Georgia State Hospital system and our outcomes speak for themselves.” ■
“Association of Treatment Facets, Severity of Manic Symptoms, Psychomotor Disturbances, and Psychotic Features With Response to Electroconvulsive Therapy in Bipolar Depression” is posted here.
“ECT Beyond Unipolar Major Depression: Systematic Review and Meta-analysis of Electroconvulsive Therapy in Bipolar Depression” is posted here.
The NEJM review titled “Bipolar Disorder” is posted here.
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Published online: 9 December 2020
Published in print: December 5, 2020 - December 18, 2020
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