Abstract
To the Editor
Electroconvulsive therapy (ECT) remains the most effective treatment for severe major depression (UK ECT Review Group, 2003), but the neuropsychological consequences can be both incapacitating and distressing. In recent years the use of ultrabrief ECT (UB ECT) in depression has become more widely accepted as it can preserve efficacy while reducing cognitive side effects (Loo et al., 2007; 2008). To date there are no reports which describe the use of UB ECT in mania or a mixed episode.
We report the treatment of a patient with a Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV-TR) mixed episode of bipolar I disorder, who was successfully treated with a course of nine right unilateral UB ECT (RUL-UB ECT). The UB pulse width was 0.3 ms rather than the standard 1.0–1.5 ms and given at six times seizure threshold.
Mrs W is a 52-year-old married mother of two children. She had a treatment history dating back to her teenage years, but after a relatively stable period of 15 years she experienced a rapid escalation in her symptoms after ceasing hormone replacement therapy 2 weeks prior to her admission. Despite a therapeutic lithium level and treatment with antipsychotic medication she became markedly elevated, grandiose, dishevelled in appearance, irritable and disorganized. She displayed a marked flight of ideas with pressure of speech and was expressing delusions with somatic, nihilistic and sexual themes. Her need for sleep was reduced to 3 h per night and her appetite was poor. She was suspicious of staff and intrusive with co-patients.
She was initially treated with a course of six RUL-UB ECT over 2 weeks. A further two sessions of RUL-UB ECT were administered on the following week and one additional session of RUL-UB ECT was administered 7 days later, taking the total number of ECT treatments to nine. The ECT dose was increased following treatment number seven when there was a decline in electroencephalogram (EEG) seizure quality. On the afternoon of the ninth and final treatment the patient was discharged from hospital.
Mood and cognitive assessments were conducted at baseline, following the third and sixth ECT treatment, and at 1 week and 3 months post-treatment.
In achieving rapid remission the patient’s mood scores as measured by the Montgomery–Åsberg Depression Rating scale (MADRS) (Montgomery and Asberg, 1979) dropped by 20 points (77%) from pre-ECT to the sixth ECT treatment, and her manic symptoms as measured by the Young Mania Rating Scale (YMRS) (Young et al., 1978) decreased by 25 points (83%). Her improvement was maintained at 3 months post-treatment. Likewise, there was an improvement in cognition. Assessments using the Neuropsychiatric Unit Cognitive Assessment Tool (NUCOG) (Walterfang et al., 2006), which examines attention, executive functioning, non-verbal and long-term declarative memory, language and visuospatial functioning revealed that total NUCOG scores had increased by 18.5 points from baseline to study end point.
This is the first report of RUL-UB ECT being administered to a patient experiencing a mixed episode who had an excellent response with no indication of memory side effects.