Thanks! Yes, by beautifully, it used to only take 3 sessions at most to see a notable difference. So this is definitely different for her. Past courses needed no more than 7 sessions before we found the plateau which was usually full remission. It's odd, once after 2 sessions of ECT she went manic. Another time when she was catatonic, we did the lorazepam thing which broke it very effectively...and she went manic with the pressured speech, increase in goal directed activity (husband left her to wait in the car one day and told her to stay put and by time he was back found her in a grocery store with a full cart rambling about a vacation home that doesn't exist), not sleeping, grandiose, definitely lost touch with reality. She's in her usual depressed state now--somatically preoccupied about being dehydrated and not eating enough. At night husband struggles but manages to get her to take meds because she fears they will kill her by the following morning, this is every time she's depressed.
Definitely wish husband would be more aggressive with the light therapy. Nothing to lose by it. But he's skeptical and does not follow through. But yet he's apprehensive of ECT too. He usually does not take her in until he's at his wits end. That or, last year I refused to see them for a follow up until they've contacted the ECT clinic and started ECT again (if the MD recommends it of course). She was so catatonic that I expressed concern of her being a DVT risk and I had a set a boundary. I've known her now for about 6 years. He keeps bugging me (yes, it's my counter transferance) to "just try another med, maybe it will perk her up". I've tried every mood stabilizer too. I've even at one point tried an MAOI (nardil--but maybe I should try another? as @clausewitz2 said, we're past the algorithm). Tried loxapine as well. No MAOI with ritalin though. Now with this round of ECT, he said for the time being he's giving up on ECT and tried to schedule another appointment with me "maybe a med change will perk her up." I responded that, med changes never have (at least under my care) and I suspect, very possibly, they never will. It just sounds so stupid--the family and I go through this every year. "not ECT yet, just try another med, just please keep trying meds if this next one doesn't work." So I coordinated with the ECT psychiatrist and got the pt and husband to follow up with him to discuss treatment planning next week, I'll be in the call via audio as well. It sounded like she may have had more of the cognitive side effects (the psychiatrist thinks this patient actually was starting to show response--husband's narrative though saw no benefit) and the ECT psychiatrist and I are thinking of continuing ECT but with more time between sessions and talking some more about the ECT technique used. He enjoys seeing this patient too and has used this case to teach medical students what bipolar I and using ECT looks like. It sounded like a combination of some more ECT side effects but also partly that husband still does not want to keep pursuing ECT and is hoping for the med route. But I'm like, totally out of meds. At least the most promising ones!
I agree, it's easier to bring someone down than up, lol! I have wondered about TMS for maintenance but there's no insurance reimbursement for that. But that angle would be very very interesting. I also agree that psychotherapy has nothing to lose and I'm not opposed. It's just hard to make progress because she keeps going back to talking about dehydration and not enough food. Then spouse chimes in with "are we gonna make a med change today?" lol
The case, which you have described in good detail, gives me the sense that there is a lot more going on in this patient’s life and history than any of us, and even you, might be aware of. The case seems off—it smells funny.
Are you absolutely sure that she is actually taking all of her medication, that there is no substance abuse, and that her labs and physical exam are unremarkable?
And why no adjunctive antipsychotic like Vraylar, Rexulti, Latuda, Geodon, Abilify, Seroquel, Abilify, Saphris, Risperdal? A regimen of Lithium, Lamictal, and an Antipsychotic would be fine if it led to stability.
It sounds like there is psychosocial chaos. There are sooo many variables in effect here, some I can potentially imagine and I’m sure many more that I can’t begin to think of and probably would be surprised to learn about. This case sounds challenging from a purely psychiatric perspective—then add all the dysfunction and inconsistency surrounding it, and this is a nightmare that would lead to many psychiatrists feeling frustrated and helpless if they didn’t realize there was MUCH more than meets the eye.
Lastly, of course, consider all the complex potential medical explanations, as you have, but don’t go to these lower probability extremes as a reaction to feeling stressed by the situation in large part due to the psychosocial disarray of the patient’s life (if there is the possibility this is happening for you). Also, don’t deny the patient’s own role and responsibility after all of these years in creating this chaotic situation that she is currently in. Hold them all responsible for their own lives. It’s not your responsibility to fix their mess—only to treat any apparent illness and to make recommendations and referrals for those things that are not in your scope or skillset. Continue to set those firm boundaries, don’t try to rescue them, and try new things (like medication regimen adjustments) and continuing ECT while optimizing as needed. Stay on your toes with this one, remain skeptical, be thorough, do what you are required to do (safety, ethics, standard of care, etc) but don’t get so lost in this case that you can’t think clearly. I’m not assuming that you are definitely experiencing any of this, just imagining what one might experience in a similar situation to yours based on what you shared.
You seem wholly dedicated and caring. Your patients are fortunate to have you.
