Role of Maintenance ECT in Bipolar I Disorder

7/30/2019 Role of Maintenance ECT in Bipolar I Disorder

1/5

1 | P a g e

Psychiatry IIYear 5, MBBS 08/09

Case Report with EBMECT in the Management of Bipolar I Disorder

Name: Harith Abdul Malek

Matric. No.: 0808-0875

Group: 04

Supervisor: Assoc. Prof Dr Muhammad Ikramul Chowdhury

Date: 03 December, 2012


2/5

2 | P a g e

Case Summary

Madam Norizan, a 50 year-old lady, diagnosed with Bipolar I Disorder over 20 years

ago, was admitted for maintenance electro-convulsive therapy (ECT). She had been put on 4-

weekly maintenance ECT since 2 years back. She was interviewed 3 hours post-ECT and sheexhibited difficulty to recall her memory and to complete serial 7 test; these were believed to

be the direct adverse effect of the ECTimmediate general cognitive and memory

dysfunction.

Her last admission was 1 month ago due to aggressive behaviour. She had been

increasingly irritable and verbally abusive for 1 week prior to the admission. She also had

insomnia and insisted for money to spend of gold jewellery. She missed her ECT appointment

which was 2 weeks prior to the onset of the manic symptoms due to travelling. However, she

denied any kind of hallucination and no delusion was elicited from her.

During this interview, Madam Norizan appeared calm and was cooperative. There

was no pressure of speech or flight of ideas. Apart from difficulty to do recalling and serial 7,

mental state examination was normal.

She is divorced and have for children who are all above 20 years old. She is being

taken care of by her second daughter who is married and has 3 children. She enjoys taking

care and play with her grandchildren. However, she has limited interaction with the

neighbours and social community at her place of stay.

Currently, apart from the 4-weekly maintenance ECT, Madam Norizan was put on

tablet Sodium Valproate, 600 mg BD, tablet Quetiapine 800 mg ON, tablet Clonazepam 0.5

mg BD. Discussion below will cover these two issues: the role of maintenance ECT and

adjunct therapy of atypical antipsychotics in bipolar disorder?

Learning Issues

1. What is the role of ECT in the treatment of bipolar disorder?

2. Is Quetiapine the atypical antipsychotic of choice in the maintenance treatment of bipolar

disorder?


3/5

3 | P a g e

Learning issue 1: What is the role of ECT in the treatment of bipolar disorder?

Malaysian Consensus Statement for the Treatment of Bipolar Disorder (2007) has

listed electro-convulsive therapy (ECT) as choice of treatment in inadequately controlled or

extremely severe acute mania, bipolar depression with high suicidal risk, psychosis, severe

depression or pregnancy, and as maintenance treatment1. ECT may be considered as a

maintenance treatment modality for patients with good response to ECT in acute phases but

have poor response to oral agents1.

Vaidya et al (2003) conducted a meta-analysis on continuation and maintenance ECT

and found that, despite methodological shortcomings, majority of the studies reported

effectiveness of ECT in treating bipolar mood disorder. They also found that even with

promising results, ECT was still underused for the treatment of bipolar disorder 2. Tsao et al

(2004) discussed on a case sample in which a patient with recurrent and severe mania who

responded very quickly with ECT after failing various combinations of oral agents 3. The

patient could only maintain euthymia with continuation of ECT3.

In 2009, Medda et al conducted a study on 130 patients with bipolar I, II disorder and

unipolar depression who would undergo two ECT course in a week. Patients with bipolar

disorder were evaluated with Young Mania Rating Scale (YMRS), Brief Psychiatric Rating

Scale (BPRS), and Clinical Global Improvement (CGI). They concluded from the study that

ECT is a viable option for treatment of unipolar and bipolar disorder resistant to

pharmacological treatment4. Petrides et al (2011) conducted a review on continuation and

maintenance ECT for mood disorders and found that continuation and maintenance ECT are

valuable treatment modalities in preventing relapse and recurrence of mood disorders in

patients who show good response to an index course of ECT5.

2 years ago, Madam Norizan was counselled on commencing maintenance ECT

treatment as she had shown some degree of intolerance to the pharmacological agents. Her

symptoms had been well controlled with consistent maintenance ECT until she missed her

appointment about 2 months back. Madam Norizan should continue the maintenance ECT

regime to prevent relapse of her manic symptoms and this will enable her to better function

in her family and society.


4/5

4 | P a g e

Learning issue 2: Is Quetiapine the atypical antipsychotic of choice for the maintenance

treatment of bipolar disorder?

Malaysia Drug Control Authority (DCA) only lists Quetiapine as an adjunct therapy to

mood stabilizers in the acute mania treatment1. Olanzapine and Aripiprazole are the atypical

antipsychotics recommended by the DCA for maintenance treatment of bipolar disorder1.

However, five randomized controlled trials (RCT) in 2008 (Young et al; McElroy et al; Nolen

et al; Vieta et al; Brecher, Anderson, & Paulsson) have demonstrated efficacy of Quetiapine as

adjunct therapy to Lithium or Sodium Valproate or as monotherapy in maintenance

treatment of bipolar disorder6. Suppes et al (2009) conducted another RCT evaluating the

effectiveness of the combination treatment of Sodium Valproate and Quetiapine as

maintenance treatment for patients with bipolar I disorder7. They found that continued

treatment of these combined agents was associated with a significant risk reduction in

recurrence of any mood event in comparison to placebo or Lithium or Sodium Valproate

alone7. Vieta et al (2012) conducted a recent review of 2 studies to assess the long-term

efficacy of combination treatment of Quetiapine with Lithium or Sodium Valproate in bipolar

I disorder and found that Quetiapine plus Lithium or Sodium Valproate significantly

increased time to recurrence of mood events versus placebo in patients with mixed symptoms

at study entry and time to occurrence of mixed-mood events in patients with any mood

episode at study entry8. The choice of Quetiapine as adjunct therapy to Sodium Valproate in

the treatment plan of Madam Norizan is in accordance to the recent evidence of its efficacy in

the maintenance treatment of bipolar I disorder.


5/5

5 | P a g e

Reference

1. Malaysian Consensus Statement for the Treatment of Bipolar Disorder. MalaysianPsychiatric Association. 2007

2. Vaidya, Nutan Atre, Mahableshwarkar, Atul, Shahid, Raheel. Continuation andMaintenance ECT in Treatment-resistant Bipolar Disorder. Journal of ECT. March

2003; 19 (1): 10-16.

3. Tsao, Carol I et al. Maintenance ECT for Recurrence Medication-refractory Mania.Journal of ECT. June 2004; 20 (2): 118-119

4. Medda P, Perugi G, Zanello S, Ciuffa M, Cassano GB . Response to ECT in Bipolar I,Bipolar II, and Unipolar Depression. Journal of Affective Disorders. November 2009;

118 (1-3): 55-59

5.

Petrides G, Kristen T, Charles K, Matthew V R. Continuation and Maintenance ofElectroconvulsive Therapy for Mood Disorders: Review of the Literature.

Neuropsychobiology. July 2011; 64 (3): 129-140

6. Hagop A & Mauricio T.Bipolar Psycho-pharmacotherapy: Caring for the Patient, 2ndEdition. Chapter 10: Quetiapine in Bipolar Disorders. Wiley-Blackwell. 2011; page

194-218

7. Suppes T et al. Maintenance Treatment for Patients with Bipolar I Disorder: Resultsfrom a North American Study of Quetiapine in Combination with Lithium or

Divalproex (trial 127). American Journal of Psychiatry. April 2009; 166 (4): 476-488

8. Vieta E, Suppes T, Ekhlom B, Udd M, Gustafsson U. Long-term Efficacy of Quetiapine inCombination with Lithium or Divalproex on Mixed Symptoms in Bipolar I

Disorder. Journal of Affective Disorders. December 2012; 142 (1-3): 36-44

Role of Maintenance ECT in Bipolar I Disorder

Documents

Transcript of Role of Maintenance ECT in Bipolar I Disorder