The Role of Electroconvulsive Therapy (ECT) in Bipolar Disorder: Effectiveness in 522 Patients with Bipolar Depression, Mixed-state, Mania and Catatonic Features

Giulio Perugi, Pierpaolo Medda, Cristina Toni, Michela Giorgi Mariani, Chiara Socci, Mauro Mauri, Giulio Perugi, Pierpaolo Medda, Cristina Toni, Michela Giorgi Mariani, Chiara Socci, Mauro Mauri

Abstract

Objective: We evaluated the effectiveness of Electroconvulsive Therapy (ECT) in the treatment of Bipolar Disorder (BD) in a large sample of bipolar patients with drug resistant depression, mania, mixed state and catatonic features.

Method: 522 consecutive patients with DSM-IV-TR BD were evaluated prior to and after the ECT course. Responders and nonresponders were compared in subsamples of depressed and mixed patients. Descriptive analyses were reported for patients with mania and with catatonic features.

Results: Of the original sample only 22 patients were excluded for the occurrence of side effects or consent withdrawal. After the ECT course, 344 (68.8%) patients were considered responders (final CGIi score ≤2) and 156 (31.2%) nonresponders. Response rates were respectively 68.1% for BD depression, 72.9% for mixed state, 75% for mania and 80.8% for catatonic features. Length of current episode and global severity of the illness were the only statistically significant predictors of nonresponse.

Conclusion: ECT resulted to be an effective and safe treatment for all the phases of severe and drug-resistant BD. Positive response was observed in approximately two-thirds of the cases and in 80% of the catatonic patients. The duration of the current episode was the major predictor of nonresponse. The risk of ECT-induced mania is virtually absent and mood destabilization very unlikely. Our results clearly indicate that current algorithms for the treatment of depressive, mixed, manic and catatonic states should be modified and, at least for the most severe patients, ECT should not be considered as a "last resort".

Keywords: Bipolar Disorder; Bipolar depression; Electroconvulsive Therapy (ECT); Mania; Mixed State; Mood stabilizer; catatonia.

References

    1. Ketter T.A. Diagnostic features, prevalence, and impact of bipolar disorder. J. Clin. Psychiatry. 2010;71(6):e14.
    1. Blanco C., Laje G., Olfson M., Marcus S.C., Pincus H.A. Trends in the treatment of bipolar disorder by outpatient psychiatrists. Am. J. Psychiatry. 2002;159(6):1005–1010.
    1. Judd L.L., Akiskal H.S. Depressive episodes and symptoms dominate the longitudinal course of bipolar disorder. Curr. Psychiatry Rep. 2003;5(6):417–418.
    1. Judd L.L., Akiskal H.S., Schettler P.J., Endicott J., Maser J., Solomon D.A., Leon A.C., Rice J.A., Keller M.B. The long-term natural history of the weekly symptomatic status of bipolar I disorder. Arch. Gen. Psychiatry. 2002;59(6):530–537.
    1. Post R.M., Baldassano C.F., Perlis R.H., Ginsberg D.L. Treatment of bipolar depression. CNS Spectr. 2003;8(12):1–10.
    1. Solomon D.A., Keitner G.I., Miller I.W., Shea M.T., Keller M.B. Course of illness and maintenance treatments for patients with bipolar disorder. J. Clin. Psychiatry. 1995;56(1):5–13.
    1. Tohen M., Frank E., Bowden C.L., Colom F., Ghaemi S.N., Yatham L.N., Malhi G.S., Calabrese J.R., Nolen W.A., Vieta E., Kapczinski F., Goodwin G.M., Suppes T., Sachs G.S., Chengappa K.R., Grunze H., Mitchell P.B., Kanba S., Berk M. 2009.
    1. Weinstock L.M., Miller I.W. Psychosocial predictors of mood symptoms 1 year after acute phase treatment of bipolar I disorder. 2010.
    1. Weinstock L.M., Strong D., Uebelacker L.A., Miller I.W. Differential item functioning of DSM-IV depressive symptoms in individuals with a history of mania versus those without: an item response theory analysis. Bipolar Disord. 2009;11(3):289–297.
    1. Anderson I.M., Ferrier I.N., Baldwin R.C., Cowen P.J., Howard L., Lewis G., Matthews K., McAllister-Williams R.H., Peveler R.C., Scott J., Tylee A. 2008.
    1. Centorrino F., Fogarty K.V., Sani G., Salvatore P., Cimbolli P., Baldessarini R.J. 2005.
    1. Fraser L.M., O'Carroll R.E., Ebmeier K.P. 2008.
    1. Kingsbury S.J., Yi D., Simpson G.M. Psychopharmacology: rational and irrational polypharmacy. Psychiatr. Serv. 2001;52(8):1033–1036.
    1. Sachs G.S., Peters A.T., Sylvia L., Grunze H. Polypharmacy and bipolar disorder: what's personality got to do with it? Int. J. Neuropsychopharmacol. 2014;17(7):1053–1061.
    1. Bates J.A., Whitehead R., Bolge S.C., Kim E. 2010.
    1. Sachs G.S., Nierenberg A.A., Calabrese J.R., Marangell L.B., Wisniewski S.R., Gyulai L., Friedman E.S., Bowden C.L., Fossey M.D., Ostacher M.J., Ketter T.A., Patel J., Hauser P., Rapport D., Martinez J.M., Allen M.H., Miklowitz D.J., Otto M.W., Dennehy E.B., Thase M.E. Effectiveness of adjunctive antidepressant treatment for bipolar depression. N. Engl. J. Med. 2007;356(17):1711–1722.
    1. Velligan D.I., Weiden P.J., Sajatovic M., Scott J., Carpenter D., Ross R., Docherty J.P. 2009.
    1. Solomon D.A., Leon A.C., Coryell W.H., Endicott J., Li C., Fiedorowicz J.G., Boyken L., Keller M.B. Longitudinal course of bipolar I disorder: duration of mood episodes. 2010.
    1. Dierckx B., Heijnen W.T., van den Broek W.W., Birkenhager T.K. Efficacy of electroconvulsive therapy in bipolar versus unipolar major depression: a meta-analysis. Bipolar Disord. 2012;14(2):146–150.
    1. Kellner C.H., Ahle G.M., Geduldig E.T. Electroconvulsive therapy for bipolar disorder: evidence supporting what clinicians have long known. J. Clin. Psychiatry. 2015;76(9):e1151–e1152.
    1. Kho K.H., van Vreeswijk M.F., Simpson S., Zwinderman A.H. A meta-analysis of electroconvulsive therapy efficacy in depression. 2003.
    1. Loo C., Katalinic N., Mitchell P.B., Greenberg B. Physical treatments for bipolar disorder: a review of electroconvulsive therapy, stereotactic surgery and other brain stimulation techniques. 2011.
    1. Mukherjee S., Sackeim H.A., Schnur D.B. 1994.
    1. UK ECT Review Group Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis. 2003.
    1. Valentı´ M.B., Garcı’a-Amador M., Molina O.B., Vieta E. Electroconvulsive therapy in the treatment of mixed states in bipolar disorder. Eur. Psychiatry. 2008;23:53–56.
    1. American; Psychiatric; Association. The Practice of Electro- convulsive Therapy: Racommendations for Treatment, Training and Privileging. 2nd ed. Washington: Americam Psichiatic Association; 2001.
    1. Grunze H., Kasper S., Goodwin G., Bowden C., Baldwin D., Licht R., Vieta E., Moller H.J. 2002.
    1. Grunze H., Kasper S., Goodwin G., Bowden C., Baldwin D., Licht R.W., Vieta E., Moller H.J., Kasper S. WFSBP Task Force On Treatment Guidelines For Bipolar Disorders. The World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for the Biological Treatment of Bipolar Disorders, Part II: Treatment of Mania. World J. Biol. Psychiatry. 2003;4(1):5–13.
    1. Kusumakar V., Yatham L.N., Haslam D.R., Parikh S.V., Matte R., Silverstone P.H., Sharma V. Treatment of mania, mixed state, and rapid cycling. Can. J. Psychiatry. 1997;42(Suppl. 2):79S–86S.
    1. Malhi G.S., Mitchell P.B., Salim S. Bipolar depression: management options. CNS Drugs. 2003;17(1):9–25.
    1. Sachs G.S., Printz D.J., Kahn D.A., Carpenter D., Docherty J.P. The Expert Consensus Guideline Series: Medication Treatment of Bipolar Disorder 2000. Postgrad. Med. 2000;(Spec No):1–104.
    1. Kellner C.H., Greenberg R.M., Murrough J.W., Bryson E.O., Briggs M.C., Pasculli R.M. ECT in treatment-resistant depression. 2012.
    1. Beale M.D., Kellner C.H. ECT in treatment algorithms: no need to save the best for last. 2000.
    1. Altshuler L.L., Post R.M., Leverich G.S., Mikalauskas K., Rosoff A., Ackerman L. Antidepressant-induced mania and cycle acceleration: a controversy revisited. Am. J. Psychiatry. 1995;152(8):1130–1138.
    1. Ghaemi S.N., Hsu D.J., Soldani F., Goodwin F.K. 2003.
    1. Homan S., Lachenbruch P.A., Winokur G., Clayton P. An efficacy study of electroconvulsive therapy and antidepressants in the treatment of primary depression. Psychol. Med. 1982;12(3):615–624.
    1. Medda P., Perugi G., Zanello S., Ciuffa M., Cassano G.B. Response to ECT in bipolar I, bipolar II and unipolar depression. 2009.
    1. Hallam K.T., Smith D.I., Berk M. Differences between subjective and objective assessments of the utility of Electroconvulsive therapy in patients with bipolar and unipolar depression. 2009.
    1. Abrams R., Taylor M.A. Unipolar and bipolar depressive illness. 1974.
    1. Black D.W., Winokur G., Nasrallah A. ECT in Unipolar and Bipolar Disorders: A Naturalistic Evaluation of 460 Patients. Convuls. Ther. 1986;2(4):231–237.
    1. Grunhaus L., Schreiber S., Dolberg O.T., Hirshman S., Dannon P.N. Response to ECT in major depression: are there differences between unipolar and bipolar depression? Bipolar Disord. 2002;4(Suppl. 1):91–93.
    1. Daly J.J., Prudic J., Devanand D.P., Nobler M.S., Lisanby S.H., Peyser S., Roose S.P., Sackeim H.A. ECT in bipolar and unipolar depression: differences in speed of response. Bipolar Disord. 2001;3(2):95–104.
    1. Sienaert P., Vansteelandt K., Demyttenaere K., Peuskens J. Ultra-brief pulse ECT in bipolar and unipolar depressive disorder: differences in speed of response. Bipolar Disord. 2009;11(4):418–424.
    1. Schoeyen H.K., Kessler U., Andreassen O.A., Auestad B.H., Bergsholm P., Malt U.F., Morken G., Oedegaard K.J., Vaaler A. Treatment-resistant bipolar depression: a randomized controlled trial of electroconvulsive therapy versus algorithm-based phar- macological treatment. Am. J. Psychiatry. 2015;172(1):41–51.
    1. Pacchiarotti I., Mazzarini L., Kotzalidis G.D., Valenti M., Nivoli A.M., Sani G., Torrent C., Murru A., Sanchez-Moreno J., Patrizi B., Girardi P., Vieta E., Colom F. Mania and depression. Mixed, not stirred. J. Affect. Disord. 2011;133(1-2):105–113.
    1. Perugi G. 2013.
    1. Swann A.C., Lafer B., Perugi G., Frye M.A., Bauer M., Bahk W.M., Scott J., Ha K., Suppes T. Bipolar mixed States: an international society for bipolar disorders task force report of symptom structure, course of illness, and diagnosis. 2013.
    1. Kruger S., Trevor Young L., Braunig P. Pharmacotherapy of bipolar mixed states. Bipolar Disord. 2005;7(3):205–215.
    1. Swann A.C., Bowden C.L., Morris D., Calabrese J.R., Petty F., Small J., Dilsaver S.C., Davis J.M. Depression during mania. 1997.
    1. Ghaemi S.N., Wingo A.P., Filkowski M.A., Baldessarini R.J. Long-term antidepressant treatment in bipolar disorder: meta-analyses of benefits and risks. Acta Psychiatr. Scand. 2008;118(5):347–356.
    1. Goldberg J.F., Harrow M., Whiteside J.E. Risk for bipolar illness in patients initially hospitalized for unipolar depression. 2001.
    1. Post R.M., Nolen W.A., Kupka R.W., Denicoff K.D., Leverich G.S., Keck P.E., Jr, McElroy S.L., Rush A.J., Suppes T., Altshuler L.L., Frye M.A., Grunze H., Walden J. 2001.
    1. Ahlfors U.G., Baastrup P.C., Dencker S.J., Elgen K., Lingjaerde O., Pedersen V., Schou M., Aaskoven O. 1981.
    1. Nelson L.A., Swartz C.M. Melancholic symptoms during concurrent olanzapine and fluoxetine. Ann. Clin. Psychiatry. 2000;12(3):167–170.
    1. Post R.M., Ketter T.A., Uhde T., Ballenger J.C. Thirty years of clinical experience with carbamazepine in the treatment of bipolar illness: principles and practice. CNS Drugs. 2007;21(1):47–71.
    1. Calabrese J.R., Rapport D.J. Mood stabilizers and the evolution of maintenance study designs in bipolar I disorder. J. Clin. Psychiatry. 1999;60(Suppl. 5):5–13.
    1. Khazaal Y., Tapparel S., Chatton A., Rothen S., Preisig M., Zullino D. Quetiapine dosage in bipolar disorder episodes and mixed states. Prog. Neuropsychopharmacol. Biol. Psychiatry. 2007;31(3):727–730.
    1. Shorter; Healy. Shock therapy: a history of Electroconvulsive therapy in mental illness. Rutgers University Press; 2007.
    1. Bailine S., Fink M., Knapp R., Petrides G., Husain M.M., Rasmussen K., Sampson S., Mueller M., McClintock S.M., Tobias K.G., Kellner C.H. Electroconvulsive therapy is equally effective in unipolar and bipolar depression. 2010.
    1. Koukopoulos A., Sani G. DSM-5 criteria for depression with mixed features: a farewell to mixed depression. Acta Psychiatr. Scand. 2014;129(1):4–16.
    1. Perugi G., Akiskal H.S., Micheli C., Toni C., Madaro D. Clinical characterization of depressive mixed state in bipolar-I patients: Pisa-San Diego collaboration. J. Affect. Disord. 2001;67(1-3):105–114.
    1. Angst J., Azorin J.M., Bowden C.L., Perugi G., Vieta E., Gamma A., Young A.H., Group B.S. Prevalence and characteristics of undiagnosed bipolar disorders in patients with a major depressive episode: the BRIDGE study. Arch. Gen. Psychiatry. 2011;68(8):791–798.
    1. Stromgren L.S. Electroconvulsive Therapy in Aarhus, Denmark, in 1984: Its Application in Nondepressive Disorders. Convuls. Ther. 1988;4(4):306–313.
    1. Gruber N.P., Dilsaver S.C., Shoaib A.M., Swann A.C. ECT in mixed affective states: a case series. J. ECT. 2000;16(2):183–188.
    1. Devanand D.P., Polanco P., Cruz R., Shah S., Paykina N., Singh K., Majors L. The efficacy of ECT in mixed affective states. 2000.
    1. Ciapparelli A., Dell'Osso L., Tundo A., Pini S., Chiavacci M.C., Di Sacco I., Cassano G.B. Electroconvulsive therapy in medication-nonresponsive patients with mixed mania and bipolar depression. J. Clin. Psychiatry. 2001;62(7):552–555.
    1. Medda P., Perugi G., Zanello S., Ciuffa M., Rizzato S., Cassano G.B. Comparative response to electroconvulsive therapy in medication-resistant bipolar I patients with depression and mixed state. 2010.
    1. Goodwin G.M. Evidence-based guidelines for treating bipolar disorder. 2009.
    1. Yatham L.N., Kennedy S.H., Parikh S.V., Schaffer A., Beaulieu S., Alda M., O'Donovan C., Macqueen G., McIntyre R.S., Sharma V., Ravindran A., Young L.T., Milev R., Bond D.J., Frey B.N., Goldstein B.I., Lafer B., Birmaher B., Ha K., Nolen W.A., Berk M. 2012.
    1. Danivas V., Behere R.V., Varambally S., Rao N.P., Venkatasubramanian G., Gangadhar B.N. Electroconvulsive therapy in the treatment of delirious mania: a report of 2 patients. 2010.
    1. Jacobowski N.L., Heckers S., Bobo W.V. Delirious mania: detection, diagnosis, and clinical management in the acute setting. 2013.
    1. Barekatain M., Jahangard L., Haghighi M., Ranjkesh F. Bifrontal versus bitemporal electroconvulsive therapy in severe manic patients. 2008.
    1. Hiremani R.M., Thirthalli J., Tharayil B.S., Gangadhar B.N. Double-blind randomized controlled study comparing short-term efficacy of bifrontal and bitemporal electroconvulsive therapy in acute mania. Bipolar Disord. 2008;10(6):701–707.
    1. Jahangard L., Haghighi M., Bigdelou G., Bajoghli H., Brand S. Comparing efficacy of ECT with and without concurrent sodium valproate therapy in manic patients. J. ECT. 2012;28(2):118–123.
    1. Mohan T.S., Tharyan P., Alexander J., Raveendran N.S. 2009.
    1. Sikdar S., Kulhara P., Avasthi A., Singh H. Combined chlorpromazine and electroconvulsive therapy in mania. 1994.
    1. Small J.G., Klapper M.H., Kellams J.J., Miller M.J., Milstein V., Sharpley P.H., Small I.F. Electroconvulsive treatment compared with lithium in the management of manic states. 1988.
    1. Vanelle J.M., Loo H., Galinowski A., de Carvalho W., Bourdel M.C., Brochier P., Bouvet O., Brochier T., Olie J.P. Maintenance ECT in intractable manic-depressive disorders. Convuls. Ther. 1994;10(3):195–205.
    1. Fink M. Rediscovering catatonia: the biography of a treatable syndrome. Acta Psychiatr. Scand. Suppl. 2013;(441):1–47.
    1. Moskowitz A.K. “Scared stiff”: catatonia as an evolutionary-based fear response. Psychol. Rev. 2004;111(4):984–1002.
    1. Kahlbaum K. Die Katatonie oder das Spannungirresein. Berlin: Verlag August Hirshwald; 1874.
    1. Caroff; Mann; Francis; Fricchione. Catatonia: From Psychopathology to Neurobiology. Washington, DC, London, England: American Psychiatric Publishing; 2004.
    1. Petrides G., Fink M. The “half-age” stimulation strategy for ECT dosing. Convuls. Ther. 1996;12(3):138–146.
    1. Starkstein S.E., Petracca G., Teson A., Chemerinski E., Merello M., Migliorelli R., Leiguarda R. Catatonia in depression: prevalence, clinical correlates, and validation of a scale. 1996.
    1. Kruger S., Cooke R.G., Spegg C.C., Braunig P. Relevance of the catatonic syndrome to the mixed manic episode. J. Affect. Disord. 2003;74(3):279–285.
    1. Blumer D. Catatonia and the neuroleptics: psychobiologic significance of remote and recent findings. Compr. Psychiatry. 1997;38(4):193–201.
    1. Fink M., Kellner C.H., McCall W.V. Optimizing ECT Technique in Treating Catatonia. J. ECT. 2016;32(3):149–150.
    1. Sienaert P., Dhossche D.M., Vancampfort D., De Hert M., Gazdag G. A clinical review of the treatment of catatonia. Front. Psychiatry. 2014;5:181.
    1. England M.L., Ongur D., Konopaske G.T., Karmacharya R. Catatonia in psychotic patients: clinical features and treatment response. J. Neuropsychiatry Clin. Neurosci. 2011;23(2):223–226.
    1. Hatta K., Miyakawa K., Ota T., Usui C., Nakamura H., Arai H. Maximal response to electroconvulsive therapy for the treatment of catatonic symptoms. J. ECT. 2007;23(4):233–235.
    1. McCall W.V. The Response to an Amobarbital Interview as a Predictor of Therapeutic Outcome in Patients with Catatonic Mutism. Convuls. Ther. 1992;8(3):174–178.
    1. Pataki J., Zervas I.M., Jandorf L. Catatonia in a University Inpatient Service (1985-1990). Convuls. Ther. 1992;8(3):163–173.
    1. Raveendranathan D., Narayanaswamy J.C., Reddi S.V. Response rate of catatonia to electroconvulsive therapy and its clinical correlates. Eur. Arch. Psychiatry Clin. Neurosci. 2012;262(5):425–430.
    1. Rohland B.M., Carroll B.T., Jacoby R.G. ECT in the treatment of the catatonic syndrome. J. Affect. Disord. 1993;29(4):255–261.
    1. Unal A., Bulbul F., Alpak G., Virit O., Copoglu U.S., Savas H.A. Effective treatment of catatonia by combination of benzodiazepine and electroconvulsive therapy. J. ECT. 2013;29(3):206–209.
    1. van Waarde J.A., Verwey B., van der Mast R.C. Electroconvulsive therapy for catatonia: treatment characteristics and outcomes in 27 patients. J. ECT. 2010;26(4):248–252.
    1. REGIONE 2006.
    1. Sienaert P., Vansteelandt K., Demyttenaere K., Peuskens J. Randomized comparison of ultra-brief bifrontal and unilateral electroconvulsive therapy for major depression: clinical efficacy. 2009.
    1. Hamilton M. A rating scale for depression. J. Neurol. Neurosurg. Psychiatry. 1960;23:56–62.
    1. Overall J.E., Gorham D.R. The brief psychiatric rating scale. Psychol. Rep. 1962;10:799–812.
    1. Young R.C., Biggs J.T., Ziegler V.E., Meyer D.A. A rating scale for mania: reliability, validity and sensitivity. Br. J. Psychiatry. 1978;133:429–435.
    1. Folstein M.F., Folstein S.E., McHugh P.R. “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J. Psychiatr. Res. 1975;12(3):189–198.
    1. Guy W. 1976. ECDEU Assessment Manual for Psychopharmacology.
    1. Bush G., Fink M., Petrides G., Dowling F., Francis A., Catatonia I. Rating scale and standardized examination. 1996.
    1. Shapira B., Tubi N., Lerer B. Balancing speed of response to ECT in major depression and adverse cognitive effects: role of treatment schedule. J. ECT. 2000;16(2):97–109.
    1. Petrides G., Divadeenam K.M., Bush G., Francis A. Synergism of lorazepam and electroconvulsive therapy in the treatment of catatonia. Biol. Psychiatry. 1997;42(5):375–381.
    1. Greenberg R.M., Pettinati H.M. Benzodiazepines and Electro-convulsive Therapy. Convuls. Ther. 1993;9(4):262–273.
    1. Andrade C., Gangadhar B.N., Swaminath G., Channabasavanna S.M. Mania as a Side Effect of Electroconvulsive Therapy. Convuls. Ther. 1988;4(1):81–83.
    1. Lewis D.A., Nasrallah H.A. Mania associated with electro- convulsive therapy. J. Clin. Psychiatry. 1986;47(7):366–367.
    1. Medda P., Mauri M., Fratta S., Ciaponi B., Miniati M., Toni C., Dell'Osso L., Perugi G. Long-term naturalistic follow-up of patients with bipolar depression and mixed state treated with electroconvulsive therapy. J. ECT. 2013;29(3):179–188.
    1. Goodwin F.K. 2007.
    1. Ketter T.A., Calabrese J.R. Stabilization of mood from below versus above baseline in bipolar disorder: a new nomenclature. 2002.
    1. Sienaert P., Peuskens J. Electroconvulsive therapy: an effective therapy of medication-resistant bipolar disorder. 2006.
    1. Minnai G.P., Salis P.G., Oppo R., Loche A.P., Scano F., Tondo L. Effectiveness of maintenance electroconvulsive therapy in rapid-cycling bipolar disorder. J. ECT. 2011;27(2):123–126.
    1. Santos P. L.; Bouckaert, F.; Obbels, J.; Wampers, M.; Simons, W.; Wyckaert, S.; Sienaert, P. Maintenance Electroconvulsive Therapy in Severe Bipolar Disorder: A Retrospective Chart Review. J. ECT. 2015
    1. Nivoli A.M., Colom F., Murru A., Pacchiarotti I., Castro-Loli P., Gonzalez-Pinto A., Fountoulakis K.N., Vieta E. New treatment guidelines for acute bipolar depression: a systematic review. J. Affect. Disord. 2011;129(1-3):14–26.

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