Electroconvulsive Therapy in a Patient With Ultrarapid Cycling Bipolar Disorder: A Case Report

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To the Editor:
Rapid cycling (RC) within bipolar disorder (BD) is usually defined as having 4 or more mood disturbance episodes within a 1-year span. When RC occurs, the treatment of BD is considered as even more difficult. There is no clear consensus with respect to the optimal pharmacological management of RC in the established guidelines. Mostly lithium and/or valproate, often in combination with an atypical antipsychotic and lamotrigine as an alternative, is recommended. Furthermore, based on case reports, the use of electroconvulsive therapy (ECT) is suggested in cases of treatment-resistant RC.
Ultrarapid cycling (URC) in BD is a subcategory of RC, which is defined as a spectrum of cycling frequencies with distinct, clinically robust mood shifts, that occur at frequencies within the course of weeks to several days.1,2 Treatment recommendations for URC are based on case reports only.
Here we report the case of a young female patient with treatment-resistant URC, who was successfully treated with ECT: a 21-year-old female patient was admitted to our clinic as an in-patient for the first time and presented with a severe depressive syndrome featuring depressed mood, loss of interest in everyday activities, loss of energy, psychomotor retardation, insomnia, and difficulties to concentrate. These symptoms had already persisted for 3 months and were accompanied by severe daytime fatigue, feeling hopeless and worthless, and thoughts of committing suicide. The patient reported that the depressive state has been discontinued by about 5 phases, lasting approximately 3 days of experiencing euphoric mood, reduced need of sleep, expanded self-esteem, and many ideas flitting in her mind. In these periods, she had been more talkative and her interest in sexual contacts had increased. Psychotic symptoms were not present throughout the whole course of illness. Psychiatric history revealed no manifest previous episodes, but subclinical depressed mood swings because she was 14 years old. No family history of psychiatric disorders was reported. A substance use disorder also could be excluded. In addition, Structured Clinical Interview for DSM-IV-I and -II interviews were performed, to rule out any other psychiatric disorders and any personality disorder. To rule out any organic disorders, we performed laboratory analyses, electrocardiogram, electroencephalogram, and cranial magnetic resonance imaging as well as analyses of the cerebrospinal fluid. These examinations did not reveal any evidence of an organic cause of the described psychiatric symptoms. The patient was diagnosed with URC bipolar II disorder. Therefore, we initially treated the patient with lithium, which had to be replaced after some days owing to severe and intolerable gastrointestinal adverse effects with extended release quetiapine, which was subsequently increased up to 600 mg per day without relevant adverse effects, but also did not show any significant alleviation of the patient's symptoms. For that reason, we augmented quetiapine after 4 weeks with aripiprazole (up to 5 mg/d; stopped because of severe akathisia and agitation) and after that with levothyroxine (up to 300 μg/d). After approximately 2 months of unsatisfactory results, we restarted lithium again. This time, the patient tolerated the medication and it was given for 4 weeks with adequate serum levels (around 0.8 mmol/L). Unfortunately, also the combination of lithium with quetiapine neither improved the depressive symptoms nor the rapidly changing mood. After altogether 15 weeks of unsuccessful and frustrating psychopharmacological treatment, we offered a course of ECT to the patient, which she agreed. Electroconvulsive therapy was performed right unilaterally starting at 5% (25.2 mC), and then, stimulation dose at subsequent treatments was given at 2.5 times the seizure threshold using a stimulus duration of 7.5 seconds, pulse width of 1 millisecond, and a frequency of 60 Hz (Thymatron IV device, Somatics, LLC, Lake Bluff, Ill).
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