Electroconvulsive therapy for manic state with mixed and psychotic features in a teenager with bipolar disorder and comorbid episodic obsessive–compulsive disorder: a case report

Abstract

BackgroundComorbidity of bipolar disorder and obsessive–compulsive disorder is common in adolescence. Obsessive–compulsive disorder symptoms may be episodic and secondary to alterations in mood, and display specific features. Management of pediatric bipolar disorder-obsessive–compulsive disorder is challenging, as pharmacotherapy of obsessive–compulsive disorder may induce or exacerbate manic episodes and there is limited evidence of treatment efficacy. Electroconvulsive therapy is sparsely used in children and adolescents, but is documented to be a safe and efficacious intervention in adults with bipolar disorder. In view of the severity of symptoms in juvenile mania, studies on treatment strategies are warranted. We report a case of an adolescent with bipolar disorder-obsessive–compulsive disorder who was successfully treated with electroconvulsive therapy during an episode of severe mania.Case presentationA 16-year-old girl of Middle East origin first presented to us with depressed mood, irritability, and increased obsessive–compulsive disorder symptoms, which were initially interpreted in the context of acute stress secondary to migration. She had been diagnosed with bipolar disorder and obsessive–compulsive disorder in her previous home country, but had difficulties in accounting for earlier psychiatric history. During hospitalization her mood switched to a manic state with mixed and psychotic features, at times showing aggression toward others. Interruption in her lithium treatment for a short period and possibly the introduction of an atypical antipsychotic could in part have been triggering factors. After 8 weeks of in-patient care and psychotropic drug trials, electroconvulsive therapy was initiated and administered every second or third day for 4 weeks, with marked positive response. No apparent side effects were reported.ConclusionsThis case demonstrates the need for a detailed medical history, taking special note of periodicity and character of obsessive–compulsive disorder symptoms, in adolescents with mood disorders. When treating culturally diverse patients, extra consideration should be taken. Special concerns in the pharmacological treatment to avoid the patient’s condition from worsening must be addressed, including giving priority to mood stabilization before obsessive–compulsive disorder symptoms. There are potential benefits in considering electroconvulsive therapy in young patients with severe mania where first-line treatment options have failed.

Electroconvulsive Therapy in Children and Adolescents

“…The primary diagnostic indication for ECT in adolescents is often severe mood disorder 23,77,78 . The efficacy of ECT has been demonstrated in cases of treatment-resistant mood disorders in adolescents, particularly unipolar depression and bipolar disorder, 24,79–83 whereas evidence for ECT in the treatment of acute mania is limited 25,26,84 . Cohen et al 85 reported 100% remission in 10 patients aged 14 to 19 years with depression and 75% remission in a sample of 4 patients with bipolar manic episodes, based on clinical impression.…”

“…23,77,78 The efficacy of ECT has been demonstrated in cases of treatment-resistant mood disorders in adolescents, particularly unipolar depression and bipolar disorder, 24,[79][80][81][82][83] whereas evidence for ECT in the treatment of acute mania is Open, prospective study 10 patients, aged 14-18 y limited. 25,26,84 Cohen et al 85 reported 100% remission in 10 patients aged 14 to 19 years with depression and 75% remission in a sample of 4 patients with bipolar manic episodes, based on clinical impression. Similar results were found by Walter and Rey 86 in 42 patients aged 14 to 17 years (51% across different diagnoses and 100% in mania) and by Strober et al 27 who found 60% complete and 40% partial remission in a sample of 10 patients aged 13 to 17 years with major depression and bipolar depression, when measured by the Hamilton Depression Rating Scale after 1 week.…”

Episódio Depressivo Grave Com Sintomas Psicóticos E Dificuldade De Acesso À Eletroconvulsoterapia Resultando Em Internação Prolongada: Relato De Caso

“…No acompanhamento pós-alta, manteve estabilidade do quadro e uso regular das medicações, com retorno completo da funcionalidade. Rask et al (2017) apresentaram o caso de uma paciente de 16 anos que se apresentou com humor deprimido, irritabilidade e aumento de sintomas de transtorno obsessivo-compulsivo, que foram inicialmente interpretados no contexto de estresse agudo secundário à imigração. Ela havia sido diagnosticada com transtorno bipolar e transtorno obsessivo-compulsivo em seu país natal, mas apresentava dificuldades em explicar seu histórico psiquiátrico anterior.…”

Comorbidade entre transtorno bipolar e transtorno obsessivo-compulsivo: aspectos epidemiológicos, clínicos e terapêuticos.

“…Os estudos envolvendo estimulação cerebral profunda e ECT, apesar de limitados, apresentam resultados relevantes sobre potenciais estratégias terapêuticas. [34,35].…”

“…Um segundo relato de caso reportou resposta satisfatória com o uso de Eletroconvulsoterapia (ECT) em paciente com SOC e em episódio misto com sintomas psicóticos. O ECT foi iniciado após 8 semanas de internação e farmacoterapia [35]. https://doi.org/10.25118/2763-9037.2022.v12.295…”