ECT for Bipolar
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Clinical Case: 39-yo WF with a h/o treatment-resistant Bipolar D/o admitted for a depressive episode and ECT. Pt noted improvement in mood after first treatment. (Pre-ECT BDI=37, mid-ECT BDI=9.)
Clinical Question: How do patients with unipolar and bipolar depression differ in response to ECT?
Validity Criteria: Therapy Study.
Follow-up: One week after final ECT session.
Randomization: UP & BP pts were randomized to 3 ECT protocols: 1) RUL ECT vs BL ECT, Voltage=1xST, 2) RUL ECT V=1xST vs RUL ECT V=2.5xST vs BL ECT V=1xST vs BL ECT V=2.5xST, 3) RUL ECT V=1.5xST vs RUL ECT V=2.5xST vs RUL ECT V=6xST vs BL ECT V=2.5xST.
Intention to Treat: Pts were analyzed in the groups to which they were allocated (UPD vs BPD) and randomized (ECT protocol).
Similar Groups: Groups were dissimilar in education , SES, # previous episodes, # previous hospitalizations, & age of onset.
Blinding: Pts were blind to ECT protocol. Evaluation team, who completed HRSD ratings (correlation coefficient>0.98) & set treatment length, was blind to ECT protocol but not diagnosis.
Equal Treatment: Withdrawal of psych meds ≥5days (except Ativan prn 3mg/day), then ECT, with no significant difference in anesthesia meds, voltage, or seizure duration.
Study Design Type: randomized, non-controlled trial.
Allocation: per diagnosis.
Blinding: Pts were blind to ECT protocol. Evaluation team, who completed HRSD ratings (correlation coefficient>0.98) & set treatment length, was blind to ECT protocol but not diagnosis.
Follow-up Period: ECT continued until: 1) Pts decided to terminate, allowable after 8 sessions if <25% decrease in HRSD or after 10 sessions if >25% decrease in HRSD, 2) Pts were asymptomatic, or 3) Pts showed plateau over ≥2 sessions.
Setting: New York State Psychiatric Institute?
Patient Population: 228 pts=162 UPD pts + 66 BPD pts (25 BPI + 41 BPII). UPD vs BPD diagnosis via SADS, RDC, with records & interviews from family & past physicians. HSRD>18 pre-ECT. Unknown race, out-pt vs in-pt. Exclusion criteria included h/o schizophrenia/schizoaffective, head injury with LOC>5min, substance abuse <1yr ago, ECT <6m ago, serious medical condition. Identical inclusion & exclusion criteria for each ECT protocol.
Intervention: ECT
Outcomes: Hamilton Rating Scale for Depression. Initial responder (IR): ≥60% reduction in HRSD & HSRD≤16 at 2d post-ECT; Final responder (FR): maintained IR gains 7d post-ECT; Remitter: FR with HRSD≤10 at 7d. Patient Follow-up: one week after final ECT session.
Main Results: There were no significant differences between BPD and UPD pts in rates of initial or final response, or remission.
–At low dosages, BL ECT was more efficacious than RUL ECT for BP & UP pts.
–BP IRs had significantly lower HRSD scores after treatment #6 (54.9% reduction in BP vs 43.9% reduction in UP IRs). No significant difference in post-ECT HRSD for IRs.
– BP pts (IRs & NRs) had significantly lower HRSD scores after treatments #4, 6, 7, 8 compared to UP pts
–BP IRs required fewer treatments to respond than UP IRs (6.33 vs 4.35= 1.98 fewer treatments, p=0.008).
–Using significant differences as co-variables, BP pts still had a more rapid response than UP pts (p=0.03).
–UP pts (all & IRs) required more sessions than BPI or BPII pts (all & IRs) (p=0.001).
Conclusions: BP pts respond sooner to ECT than UP pts. While this study demonstrates the possible utility of ECT in BP depression, it is unlikely that the small difference in time of response, 1.98 treatment sessions earlier, will have significant clinical impact.
Teaching Points: Log-Normal: Calculating the logarithm of data can be used to convert skewed data to have a normal distribution.
Questions for Discussion: 1. “Theoretically, it is conceivable that early induction of hypomania was responsible for the rapid antidepressant effects seen in BP patients.” 2. What is the effect of h/o mood stabilizer (anti-convulsant) use on ST in BP pts?
Presented by Christy Kubit MD on 9/18/2006
