Role of Electroconvulsive Therapy, Ketamine Infusion, and Deep Repetitive Transcranial Magnetic Stimulation in Treatment-Resistant Bipolar Depression: A Case Report
Abstract
:1. Introduction
2. Case Presentation
2.1. Initial Evaluation
2.2. Follow-Up Treatments
2.3. ECT and Post-ECT Treatments
2.4. Ketamine Infusion
2.5. dTMS Treatment
2.6. Post-dTMS Follow-Up Visits
3. Discussion
4. Clinical Applications
5. Conclusions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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Time of Treatment | Cumulative Number of Treatments | QIDS-16-SR Total Scores | Change from Baseline | MoCA Total Scores | Psychiatric Assessments |
---|---|---|---|---|---|
Baseline | n/a | 20 | n/a | 24 | Prior to the first ECT (electroconvulsive therapy) treatment, she reported feeling very depressed, a lack of motivation and pleasure, and anxious daily all the time, with a severity of 8 out of 10 (ten being the worst). Per herself, she did not do anything at home and just sat in a chair rocking back and forth. She also reported that she felt hopeless, helpless, and worthless and feared her future. She slept well with quetiapine 50 mg at bedtime. Her energy was low. Her concentration, cognition, and memory were not good, and she could not write or spell. She did not have an appetite, ate less, and lost 10 pounds in the last 2 months. She denied having suicidal ideation (SI), homicidal ideation (HI), auditory or visual hallucinations (AVHs), or paranoia. |
During and after week 1 | 1–2 (Wednesday, Friday) | 19 | −5% | 27 | There was no change in mood and other depressive symptoms, although she reported feeling less anxious after the 1st ECT. She did not feel any difference after the 2nd ECT. She reported feeling very depressed, with suicidal ideation, but denied having a plan or intent. |
During and after week 2 | 3–5 (Monday, Wednesday, Friday) | 15 | −25% | 26 | She did not feel much different after the second week of ECT treatments. She scored her depression as 7–8 out of 10 (ten being the worst). She reported feeling hopeless, helpless, and anxious but denied having SI, HI, AVH, or paranoia. She was not sure if ECT helped her or not. As per her significant other (SO), she seemed a little better. |
During and after week 3 | 6–8 (Monday, Wednesday, Friday) | 9 | −55% | 21 | After the 6th treatment, she reported feeling better and less depressed and scored her depression 3 out of 10. She did not feel hopeless, helpless, or worthless anymore. After the week 3 treatment, she reported she had about 50% improvement and was able to force herself to eat more. |
During and after week 4 | 9–11 (Monday, Wednesday, Friday) | 7 | −65% | 24 | During the week 4 treatment, she continued feeling better but started feeling forgetful. She reported feeling depressed intermittently, with a severity of 3 out of 10, and being active at home. As per her SO, she showed some “manic” symptoms, because she wanted to be on social media again. After the 11th treatment, as per her SO, she did break into her SO’s computer and was on social media for several hours over the weekend. No other manic symptoms were reported. |
After week 5 | 12 Monday | n/a | n/a | n/a | Not available. |
Time of Treatment | Cumulative Number of Treatments | QIDS-16-SR Total Scores | Change from Baseline | Psychiatric Assessments |
---|---|---|---|---|
Baseline | n/a | 20 | n/a | Prior to the 1st ketamine infusion, she reported feeling very depressed and anhedonia daily, with a severity of 10 out of 10 (ten being the worst). She reported ruminating on what she did when she was manic and feeling hopeless, helpless, and worthless on and off, but denied having SI (suicidal ideation). She also denied having HI (homicidal ideation), AVH (auditory or visual hallucination), or paranoia. She continued having problems with sleep, appetite, energy, and concentration, with weight loss even with olanzapine. |
During and after week 1 | 1–3 (Monday, Wednesday, Friday) | 22 | +10% | She reported feeling a little better and did not stay in bed all the time after the first infusion, but she did not feel much different after the second one. She reported continuing to feel depressed most of the time, with moderate/severe symptoms and passive SI on and off, and she continued losing weight due to no appetite. She wanted to die because of psychological pain. Overall, she felt somewhat different, but not much, and even became worse over a long holiday weekend. |
During and after week 2 | 4–6 (Monday, Wednesday, Friday) | 15 | −25% | She did not feel much different after the 4th infusion. She continued feeling very depressed with SI but denied having a plan or intent. She still isolated herself and stayed in bed most of the time. She forced herself to eat more. She did not want to be hospitalized and promised that she would change her behavior to prevent further deterioration and hospitalization. She reported feeling 20–30% improvement after the 5th infusion and believed ketamine infusion would work for her, although she continued feeling hopeless periodically, with moderate symptoms most of the time. Overall, she had some improvement after a total of 6 treatments. |
During and after week 3 | 7–9 (Monday, Wednesday, Friday). | 18 | −10% | After the 7th infusion, she reported feeling markedly improved and scored her depression about 4 out of 10 (ten being the worst), but her QIDS-16 score was 16 points, indicating the depression was still severe. After the 8th treatment, she continued reporting feeling better, was able to stay out of her bedroom, had conversations with her husband, and started reading. She reported eating better and gaining some weight, but she did not do well over the weekend, isolated herself, and stayed in her room most of the time because of psychological factors and ruminating on her past. |
During and after week 4 | 10–11 (Monday, Friday | 16 | −20% | She reported that ketamine infusion was helpful and made her strong enough to handle her depression and her guilt about her past. She reported sleeping well and eating more, with some weight again. As per her SO, her mood was unstable, and they were not sure if it was worth continuing ketamine infusion. She decided to have weekly ketamine infusion thereafter. |
After week 5 | 12 | 15 | −25% | She said she felt better and had 5 days of relatively “normal” and 2 days of severe depression. During those 2 days, she stayed in her bedroom most of time and rocked back and forth. During the relatively “normal” days, she was able to talk to her SO and her sister and stay out of her bedroom most of the time. She reported sleeping better, eating better, and gaining some weight. She denied having SI, HI, AVH, or paranoia. |
After week 6 | 13 | 11 | −45% | She reported reaching a plateau with ketamine infusion. Still felt depressed, anhedonic, and anxious intermittently, with mild to moderate symptom severity. She continued eating better, gaining weight, and sleeping well with medications. |
After week 7 | 14 | 12 | −40% | She reported feeling more depressed again but not as severe as before. She wanted to continue ketamine infusion because she felt it was helpful. |
After week 8 | 15 | 17 | −15% | She reported feeling alright and relatively stable, with daily moderate depression intermittently. She was able to engage in some family activities. Still ate better and slept satisfactorily with medications. |
After week 9 | 16 | 15 | −25% | She reported that her mood had “ups and downs” and generally improved with ketamine infusion. |
After week 10 | 17 | 14 | −30% | She reported feeling better and relatively stable but still felt depressed intermittently, with mild to moderate symptoms. She enjoyed some activities with her family. She continued eating well and gaining weight and slept well with medications. |
After week 11 | 18 | 14 | −30% | She reported feeling better and stable, with about 80% of her “normal”, but she still felt very depressed periodically. |
After week 12 | 19 | 10 | −50% | She reported feeling alright as well as eating well and sleeping well, and she believed ketamine infusion helped her to some extent. As per her SO, she did not do well in the past week. |
After week 13–14 | 20 | 9 | −55% | She reported feeling alright and did not feel much different compared to the previous week. As per her SO, ketamine infusion had reached the maximum benefit for her, and she was unstable, isolating herself at home, lacking motivation, and rocking back and forth in her room most of the time. |
After week 15–16 | 21 | 11 | −45% | She reported not doing well and had more bad days than good days. During bad days, she stayed in her room most of the time and felt more depressed and more anxious, but she denied having SI/HI/AVH or paranoia. She decided not to have more ketamine infusions. |
After week 17 | 22 | n/a | n/a | No assessment due to completion of treatment. |
Time of Treatment | Cumulative Number of Treatments | QIDS-16-SR Total Scores | Change from Baseline | Psychiatric Assessments |
---|---|---|---|---|
Baseline | n/a | 17 | n/a | Prior to the first dTMS (deep transcranial magnetic stimulation), she reported continuing feeling depressed and anhedonic more than half of the time, feeling hopeless, helpless, and worthless intermittently, but denied having SI (suicidal ideation), HI (homicidal ideation), AVH (auditory or visual hallucination), or paranoia. As before, she stayed in her bedroom most of the time rocking back and forth in a chair. Her energy was low. Her concentration was poor. Her appetite was not good, even with olanzapine 10 mg/day. She also felt restless and easily irritable. |
During and after week 1 | 1–4 | 12 | −29% | She reported feeling alright and hopeful after the 1st dTMS because she did not have severe side effects. During the first week of TMS treatment, she felt optimistic, ate more, and slept better. Her energy and concentration were gradually better. She became more active at home and was able to participate in some family activities. She also realized she had been too critical to herself, which made her unstable. She reported having some anxiety throughout the week, but her irritability went away at the end of the week. |
During and after week 2 | 5–9 | 8 | −53% | During the second week of treatment, she continued reporting improvement in her mood, motivation, pleasures, interest, activities, energy, concentration, appetite, sleep, and anxiety. At the end of the week, she did not feel persistently depressed anymore, although she still had bad days. She also reported that her mood was more stable. |
During and after week 3 | 10–14 | 9 | −47% | Overall, she felt good and relatively stable. She believed that dTMS had been helpful, although she still felt depressed 15–20% of the time, with mild depression intermittently. She reported that she was able to soothe herself with reading, cooking, or social media. She felt close to “normal”. Her SO confirmed her reports. |
During and after week 4 | 15–19 | 3 | −82% | Prior to the first treatment of week 4, she reported feeling 100% better for more than a half of the time. During the entire week, she reported feeling close to 95–100% “normal” and had anxiety and depression occasionally. |
During and after week 5 | 20–22 | 3 | −82% | Prior to the first treatment of week 5, she reported not feeling well because she had a big argument with her SO over her use of social media, which caused her problems when she was manic. She admitted that she was addicted to social media and realized it was a problem for her. She reported feeling depressed and anxious for about 1 day, with a severity of depression of 7 out of 10 (ten being the worst), but was able to recover quickly and function well. |
During and after week 6 | 23–25 | 5 | −71% | Prior to the first treatment of week 6, she reported not feeling well because she was ruminating on what she did on social media last week, with the fear of ruining her reputation again. She felt miserable and discouraged but did not feel depressed. She reported that she “recovered” again after 2 days. |
During and after week 7 | 26–28 | 3 | −82% | During the entirety of week 7, she reported feeling very good and enjoying the time with her family, and she denied having other symptoms of depression. As per her SO, she was better and had more good days than bad days. |
During and after week 8 | 29–31 | 5 | −71% | During the entirety of week 8, she reported that she felt pretty good and stable and denied having depressive symptoms. |
During and after week 9 | 32–35 | 5 | −71% | During the entirety of week 9, she reported feeling close to “normal” and trying to think positive. She admitted that she tended to slide back to depression quickly, even there was no specific trigger. |
During week 10 | 36–39 | n/a | n/a | Prior to the first treatment of week 10, she reported she felt a little “dip” but was able to participate in family activities. During the week, she felt good and “normal”. |
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Gao, K. Role of Electroconvulsive Therapy, Ketamine Infusion, and Deep Repetitive Transcranial Magnetic Stimulation in Treatment-Resistant Bipolar Depression: A Case Report. Medicina 2024, 60, 936. https://doi.org/10.3390/medicina60060936
Gao K. Role of Electroconvulsive Therapy, Ketamine Infusion, and Deep Repetitive Transcranial Magnetic Stimulation in Treatment-Resistant Bipolar Depression: A Case Report. Medicina. 2024; 60(6):936. https://doi.org/10.3390/medicina60060936
Chicago/Turabian StyleGao, Keming. 2024. "Role of Electroconvulsive Therapy, Ketamine Infusion, and Deep Repetitive Transcranial Magnetic Stimulation in Treatment-Resistant Bipolar Depression: A Case Report" Medicina 60, no. 6: 936. https://doi.org/10.3390/medicina60060936