Role of Maintenance ECT in Bipolar I Disorder
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Transcript of Role of Maintenance ECT in Bipolar I Disorder
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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
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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?
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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.
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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.
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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