Electroconvulsive therapy in bipolar affective disorder

Electroconvulsive therapy (ECT) is a well-established treatment for several psychiatric conditions. However, it does not currently loom large in either the public conscience or in medical literature, and can easily slip under the radar when considering treatment options. In this article, we present a case in which it has proven extremely effective for a depressive relapse in a patient with bipolar affective disorder (BPAD) followed by an analysis of the role of ECT in affective disorders of the older patient.

What is bipolar affective disorder?

Bipolar affective disorder (BPAD) is a chronic mood disorder characterised by both depressive and manic, or hypomanic, episodes. By definition, these episodes must significantly affect the patient’s day-to-day functioning. BPAD affects 0.5-1.0 % of adults over the age of 60 years, rising to 4-17% among older patients receiving treatment for psychiatric conditions.¹

In this population, BPAD includes new-onset illness, plus illness that has persisted after having manifested earlier. Although the incidence of bipolar affective disorder is lower in the older population (over 65 years) compared to the younger population, older-age bipolar disorder (OABP) remains a significant cause of morbidity,² and thus an important public health matter.

Studies have indicated that the clinical presentation of bipolar disorder in older patients is characterised predominantly by depressive features,³ for reasons poorly understood. Older patients are also more likely to display ‘melancholic’ features, chiefly psychomotor retardation, vegetative symptoms (including loss of appetite and insomnia) and anhedonia.^4,5

In addition, manic episodes are less euphoric, with increased irritability and paranoia dominating.^4,5 Other research focusing on these depressive episodes in OABP has shown that most patients report loss of interest (86.9%) and low mood (78.5%), alongside physical symptoms, including loss of appetite (30.3%), sleep disturbance (71.1%) and lack of energy (83.2%).⁶

Older patients experiencing a depressive episode are less likely to present with psychotic features than younger patients. Nonetheless, they still pose a therapeutic challenge, presenting with symptoms such as guilt, percusatory delusions and ideas of self-deprecation.⁷ Ultimately, the role of severe depressive episodes, such as that experienced in this case, cannot be ignored in OABP as they often prove challenging to treat and have a high rate of mortality.

Case report of older woman with bipolar affective disorder

Clinical history

A 74-year-old lady was reviewed by her GP at the request of the nurse attached to the retirement complex in which the patient lived. She had deterioration in appetite leading to significant weight loss. This presentation was thought to have been precipitated by a social event in the complex, in which she was encouraged to mix with other residents and perform activities with which she was uncomfortable. The antecedent symptoms included increasing social withdrawal and anxiety.

The patient had a 20-year history of BPAD, with a relapsing and remitting pattern. Other medical history included hypothyroidism, and osteoarthritis affecting multiple joints. Her medication was sertraline, mirtazapine, sodium valproate, levothyroxine, mirabegron, prophylactic nitrofurantoin and omeprazole.

On examination she appeared thin, pale, and anxious. Her weight was 47kg, an 11kg reduction from six months previously. Physical examination was unremarkable and routine blood tests, including a myeloma screen, full blood count, renal, liver and thyroid function tests were normal, as was urine culture.

Due to the patient’s significant deterioration, she was urgently referred to the mental health team. Over the subsequent months, despite several changes in her medication, she deteriorated further and developed psychotic symptoms, included a belief that food was sticking to her lips and gums, causing her to stop eating altogether. Despite changing her antidepressant to venlafaxine and commencing olanzapine, she continued to lose weight, another 3kg over the subsequent months, and her BMI dropped to 18.

She was finally admitted to a psychiatric inpatient facility and received eleven sessions of ECT over eight months. Her mood improved significantly after the first six treatments, such that she was discharged home to have the remaining five treatments as an outpatient. Her appetite improved and her weight increased to 56kg. She had become markedly brighter in herself and much more engaged with other residents, and started to show an interest in activities she had enjoyed prior to this relapse. In this case the patient responded remarkably well to ECT, leading to an effective, and possibly life-saving, response.

Differential diagnosis for bipolar affective disorder

Given this history, the differential diagnoses that had to be considered in an elderly patient presenting with considerable weight loss included:

• Malignancy
• Non-malignant gastrointestinal disease
• Medication side-effects
• Endocrine, particularly diabetes and thyroid disease
• Severe depressive episode
• Dementia
• Stroke
• Social causes: isolation, barriers to obtaining food.

As physical examination was unremarkable and routine blood tests normal, severe depression (with psychotic features) emerged as the most likely cause when the patient’s history of bipolar affective disorder was factored in.

Use of electroconvulsive therapy in affective disorders in the older population

Electroconvulsive therapy (ECT) uses electrical impulses to induce seizures to treat a variety of psychiatric conditions. ECT is commonly used in older patients. A 2002 survey looking at ECT use in England reported that 47% of female patients and 45% of male patients who received ECT were aged 65 or above.¹

ECT use in OABP is a topic that has received little attention despite its extensive use in this population. For this reason, and because ECT use is equally effective in major depressive disorder (MDD) and BPAD,⁸ we shall discuss literature relating to ECT use in all types of affective disorders in various age groups within the adult population.

Studies have shown that ECT is not only effective in treating affective disorders in the older population, but that remission and rate of response is higher in this age group compared to younger patients.^9,10 Indeed, age is a significant predictor of positive response to ECT.¹¹

Moreover, ECT is thought to be a more effective treatment compared to pharmacotherapy for affective disorders. There are several biomechanical factors to explain this. Firstly, changes in pharmacokinetics and pharmacodynamics of psychiatric medications with age can render drug therapies ineffective, poorly tolerated, or toxic. For example, lithium, one of the most commonly used drugs in BPAD, poses significant problems in the elderly. Due to age-related changes, such as increased blood-brain barrier permeability and decreased renal function, the risk of lithium accumulation and toxicity in greater in elderly patients¹² and neurotoxicity occurs even at moderate plasma concentrations.¹³

Furthermore, polypharmacy in the older patient may cause drug interactions, leading to further side effects. Common drugs, such as diuretics, NSAIDs, ACE inhibitors and calcium channel blockers have significant interactions with lithium.¹⁴

Medical contraindications to psychopharmacological treatments, such as the presence of upper gastrointestinal bleeding with the use of SSRIs, further complicate drug therapy in the elderly. Secondly, in several studies ECT has been shown to be superior for affective disorders in the elderly compared to medication.^15-18

One study showed faster rates of remission in patients over 60 with MDD treated with ECT compared with medication.¹⁹ This has clear implications for the choice of treatment for older patients in which a swift recovery is required to prevent further deterioration. Such patients may include those with psychotic or vegetative symptoms, who may have ensuing physical sequelae such as poor nutritional status. In these patients, ECT may facilitate rapid recovery since the presence of psychotic and vegetative symptoms are independent predictors of response to it.^20,21

The current barriers for ECT use in the older patient include the risks and adverse effects related to the procedure. Cardiovascular comorbidities can be a relative contraindication to ECT, as the electrical impulses induce vascular changes that transiently increase the risk of cardiovascular events. However, two older studies have shown that whilst patients with cardiovascular risk factors are at slightly increased risk of adverse events during the procedure, ECT remains a safe method of treatment for these patients.^22,23

While the risks of cardiovascular events due to ECT are increased in the older patient,²⁴ these risks can be mitigated by good control of risk factors. For example, uncontrolled hypertension is a relative contradiction to the procedure, but once well controlled appears to be safe.²⁵

Memory loss (anterograde and retrograde amnesia) and post-ictal confusional states are significant side effects that must be factored in when considering ECT. Cognitive decline has been shown to be transient following ECT, but older age is associated with higher rates of postictal cognitive decline.²⁶ There is no evidence that ECT is associated with an increased risk of dementia;²⁷, however, in older patients who have dementia, the risk and magnitude of cognitive side effects are increased. One study showed that post-ECT confusional scores are correlated with the degree of dementia.²⁸ However, further research has shown that cognitive deficits are transient in patients both with and without pre-existing cognitive impairment.²⁹

Deficits in processing speed, working memory and anterograde memory last on average 15 days before returning to baseline.³⁰ The use of unilateral ECT probe placement is suggested to reduce the severity of cognitive impairments post-ECT in older patients, and is thought to be of comparable efficacy to bilateral ECT.³¹  Therefore, the use of unilateral ECT may be appropriate. Further efforts to reduce the impact of cognitive decline are the subject of an ongoing clinical trial to assess the use of cognitive training as a means to improve post-ECT memory loss.³²

Postictal delirium is another side-effect that is of particular relevance to the elderly. A recent study showed a greatly increased risk of delirium following ECT in adult patients on lithium.³³ The percentage of patients who experienced delirium treated with both lithium and ECT was small (5.7%), but may be higher in the very elderly. Therefore, further monitoring of lithium levels and screening for delirium is warranted in this population. Additional risk factors were described in a recent systematic review which concluded that catatonic features, cerebrovascular disease, Parkinson’s disease, dementia, bitemporal electrode placement, high stimulus intensity and longer seizure length are all associated with an increased risk of post-ECT delirium.³⁴

The same review suggested that dexmedetomidine and ultrabrief pulsed ECT decrease the risk of post-ECT delirium, and therefore may be used as preventative measures in high-risk patients. As with cardiovascular complications, careful consideration of possible risk factors for cognitive side effects and delirium should be considered by a multidisciplinary team. In addition to this, cognitive function should be measure pre-procedure, and periodically post-procedure to assess any decline in function.

Conclusion

ECT is an important treatment method to consider in patients with BPAD presenting with primarily depressive symptoms, and in cases of treatment-resistant depression amongst the elderly population. Furthermore, ECT is especially important to consider in patients who require an expedited recovery or who have contraindications to medication. Despite evidence indicating its efficacy and its extensive use in the older population, there remains a paucity of literature on the use of ECT to treat BPAD in the this age group.

More research into ECT use in the older patient is therefore merited. As delirium and cognitive decline remain significant barriers to more widespread use, further investigation into how to mitigate these adverse effects is required. ECT is overwhelmingly a safe and effective treatment and, as this case demonstrates, can often be life-saving.

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Caitlin Norris-Grey, Anastasia Krywonos, medical students, University College London Medical School, London

David Turner, Edin Lakasing, GPs and Tutors, Chorleywood Health Centre,  Hertfordshire

Email: [email protected]

Competing interests: none

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