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
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 –
Published November, 2009