Electroconvulsive Therapy in Bipolar Mixed States: An Overlooked Option

Abstract

aBipolar Disorders Program, Hospital Clinic, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain. *Corresponding author: Andrea Murru, MD, PhD, Bipolar Disorders Program, Hospital Clinic Barcelona, IDIBAPS, CIBERSAM, c/Villaroel 170, Barcelona, 08036, Spain (amurru@clinic.ub.es). J Clin Psychiatry 2015;76(9):e1149–e1150 dx.doi.org/10.4088/JCP.14com09407 © Copyright 2015 Physicians Postgraduate Press, Inc. M ixed affective states are complex presentations of bipolar disorder that represent a diagnostic and therapeutic challenge for clinicians and researchers alike. Treatment guidelines do not usually recommend specific treatments for mixed states, as patients suffering from mixed episodes are generally included as a subsample in trials on acute mania. In clinical practice, mixed presentations in bipolar disorder are largely assumed to have a poorer response to treatment than mood episodes without mixed features. The present issue of the Journal presents a compelling article by Medda and colleagues1 on the acute use of electroconvulsive therapy (ECT) in a sample of 197 bipolar patients suffering from a severe, drug-resistant mixed state. The sample presented in this study represents a subset of especially difficult-to-treat bipolar patients. Nonetheless, the study clearly suggests that ECT is an effective treatment in mixed conditions, with 82 patients (41.6%) considered responders and 60 patients (30.5%) considered remitters. In the prediction model presented, the authors underline the role of comorbidity with obsessive-compulsive disorder, baseline manic symptom severity, and duration of the current episode as predictors of nonresponse to ECT.1 Despite the major limitations of the lack of random allocation of the patients included and the lack of evaluation for rapid-cycling, Medda and colleagues1 have the merit to provide insight on the clinical management of especially difficult-to-treat patients derived from their tertiary care unit and to focus on a therapy that is often neglected and rarely investigated. Mixed states represent a well-described clinical feature in the course of bipolar illness. Mixed states have been associated with the use or overuse of antidepressant treatments, which could play a role in their incidence in clinical practice, especially with dual-action serotonin–norepinephrine reuptake inhibitors,2 and with an increased suicidal risk.3 The iatrogenic role of antidepressants in mixed states is far from being demonstrated; yet, a recent international consensus agreed on the recommendation to discontinue antidepressants during manic and depressive episodes in patients who present mixed features or who have a tendency to present predominantly mixed states.4 In the recent update of the American Psychiatric Association diagnostic criteria (DSM-5), the strict criteria for mixed episode have been replaced with episode specifiers that will, as a consequence, increase the prevalence of mixed states in clinical practice,5 possibly broadening the usefulness of treatment recommendations specifically aimed at mixed states. This update creates an urgent need for more trials that provide separate results for mixed-states subsamples. Given the lack of studies designed to address the efficacy of medications in mixed affective symptoms, guidelines do not fully reflect the current evidence.6 The situation seems even worse in the case of depression with mixed features, in which the scarcity of researched treatment options often clashes with a clinical management that relies maybe too strongly on antidepressants.