Q:  Questions re: ECT

Dear Dr. Phelp's,

I have been diagnosed with rapid cycling Bipolardisorder or 12 years now.  Yes, I have tried every medication, was hospitilized 3 times, and now I began ECT.  I went for 3 treatments so far.  How many treatments in general does it usually take before you notice a difference?  When I come home, it takes me a few days to recover, as my temples have a big headache, I am spacy, and I have 3 children to care for.  The last time, the Nurse did not put the gauze in my mouth correctly and part of my tongue has a laceration on it.  Sometimes I wonder if all of this is worth it, but it is in reality my last hope.  Are you confident in this procedure?

Thank you
 

Dear Ms. T' --
I have patients whom I've referred for ECT, for whom it clearly works in terms of symptom reduction, who are now "back" with me (I don't do ECT myself, for some complex reasons, but there's no doubt it works, amazingly frequently even though we usually only turn to it when many other things have already been tried) and we're hunting for additional medication approach alternatives because they for one reason or another don't want to continue with "maintenance" ECT, even though it's working.  

With the current rate of new medication showing up, I've been able to "stay ahead" and keep coming up with alternative medication approaches, but the patients know that we're using new things before I would usually be doing so (usually I like to let others find out what the real risks and side effects are before I get going with a new treatment; like my dentist says, "I don't like to be at the front of the pack, or at the back of the pack; somewhere near the middle is good").  

For example, aripiprazole ("Abilify" -- it sticks in my throat every time, that name) is looking pretty good so far in the literature, though everything looks better when it first comes out than it will later.  And there are definitely some patients out there for whom Geodon is a good thing, though I have trouble finding them among the rest for whom it has little benefit.  

But in the vast majority of cases where we've struggled for up to years to get mood stability, what finally ends up working is a combination of mood stabilizers at low doses, sometime up to 4 or 5 of them, while always being very vigilant about antidepressant-induced cycling in those who are still on an antidepressant in the mix.  

There is a mathematical formula for this, I recall, working out the different permutations of combining five different mood stabilizers, but suffice to say that very few patients referred to me have had all such permutations, probably few even of my own patients.  There are examples of folks who've had a really remarkable number of medications tried who hit on something that really works well, two of which I've shown in an essay on hope.  So although it's not as exciting as hoping the next "new" medication is going to be "the one", just plugging away at combining mood stabilizers has been the thing that eventually ends up helping most of my patients (while keeping the doses below the side effect level of each).  

In your situation, for example, depression is probably one of the more major symptoms (as ECT is not commonly the route for predominant manic-side symptoms).  I'll bet you haven't had lamotrigine combined with Depakote, as that combo scares people because of the known interaction (not dangerous per se, they just increase each others' levels and so have to be very carefully managed), or combined with Zyprexa (which might have to be combined with amantadine or glucophage to prevent weight gain).  Ok, maybe you've had that.  How about that combined with some form of thyroid?  You see, it just goes on and on, if you get down to detail, the number of potential combinations you'd have to try before you can really say "I've had everything").  Not exciting, backtracking to things you've already done and then adding something like thyroid, and in each case the likelihood of something dramatic happening may be very low, but the likelihood of something smaller may be quite a bit higher.  

Good luck to you in your search. 

Dr. Phelps
 

Published September, 2003