Q:  Asks for an Opinion of the Use of ECT in the Treatment of Bipolar NOS

What is your opinion of the use of ECT in the  treatment of Bipolar NOS? My own  doctor is ambivalent.  I am on many  medications, including lamictal, an antidepressant, an anxiolytic, and concerta.   I just want  to get off the drugs and get back to as normal a life as possible.   My symptoms are sometimes deep depressions then  dysphorica  ?) and then  hypomania (irritability, anxiety, anger, agitation, distractibility).  I've gone  through about every anti-depressant  available and they sometimes work but then  stop or they don't work at all (like Wellbutrin and Serzone).  This has been going  on my whole life.  I was treated for depression only until about 6-7 years  ago when a bipolar type diagnosis was made.  Thanks if you can help with this or maybe point to some studies I can share with my psychiatrist.

 

Dear John –

ECT for bipolar disorder? I’ll get ‘round to that question by the end here, but first you might look at the idea of revisiting some of the least bothersome mood stabilizers, at very tolerable doses, using at least two together and perhaps three – all without an antidepressant on board.

As you may know, the role of antidepressants in the treatment of bipolar disorder is controversial. I’ve summarized those controversies, with a selection of research articles that support my point of view (with a tip of the hat in most cases to alternative points of view), on my Antidepressant Controversies page.

On that page you might pay particular attention to the data – what very little there is – supporting the idea that antidepressants can induce cycling. If that’s true, and it appears to be true for at least some people, then antidepressants could work contrary to what our “mood stabilizers” (e.g. lamotrigine and low-dose lithium, one of my favorite combinations) are trying to do, namely stop the cycling.

So, if you’re still cycling, maybe you don’t need a better antidepressant and maybe you might even need fewer or lower-dose mood stabilizers, if you’re lucky (but don’t get hopes up, you might not be lucky, and raised hopes can lead to dashed hopes). Maybe you just need to first try taking the antidepressant out. That’s to be discussed with your doc’ first, of course, not done on your own. Some people need to taper them extremely slowly (e.g. 4 months; here’s my diatribe on that) to get off of them without seeing things get worse – which of course makes them all the more convinced the antidepressant needs to stay in there, effectively leaving them stuck on the antidepressant, so we don’t want that.

To answer your question more directly, however, though this is a brief very generalized answer and there might be role for ECT for some people with bipolar disorder as a maintenance agent (it certainly has a role as a direct intervention for depression, although frankly I think sleep deprivation, done right, is beginning to look like something everyone would want to try first; a hospital in Milan even has a standard protocol for this approach and makes it available three times a week, rather like ECT).

The problem with maintenance strategies, though, is that they have to go on for quite a while. That is, if you get better on ECT, how are you going to stay well? Many ECT centers offer “maintenance ECT”, where after originally getting a treatment 2 or 3 times a week to get better, you keep coming back, working down to once a month or so, for ECT as a preventive tool.

That might be okay for a while but eventually just about everybody is going to be looking for some alternative solution that does not require these interruptions of daily life, for one thing. And some experts think there ought to be a lifetime cap on the number of ECT sessions a person has, because after about 50, I’ve heard some estimate, the treatments may actually start causing some lasting damage (as you know, the damage story is also controversial, with some very loud voices on the internet claiming it’s right away, not after 50 sessions, but the evidence does not support their concerns, at least overall).

So that’s why my mind goes first to looking for the approach you may not have had yet, instead of ECT. And the approach outlined above is one I reach for first, not at the very last, so if you’ve not had it (combination mood stabilizers without an antidepressant), there’s something else left to try before turning to things like ECT. You might also check out my essay on Dark Therapy, as an additional idea that may not have been tried yet (very cheap and very unlikely to harm, even though there’s only one randomized trial of it so far…).

Good luck with your search –

Dr. Phelps

Published November, 2009