When electroconvulsive therapy fails: cognitive– behavioral therapy in treatment-resistant bipolar depression. A case report

Background: Electroconvulsive therapy (ECT) is one of the standard treatments for treatment resistant bipolar depression (TRBD). There is limited literature on the role cognitive-behavioral therapy (CBT) in TRBD patient who fails to respond to ECT. Aim: To report a case of patient achieving full functional recovery with CBT in combination with pharmacotherapy after failing to respond to ECT. Method: Case report. Results: A 45 year-old male with diabetes mellitus, diabetic retinopathy, and bipolar II disorder presented with a third recurrence of depressive episode. In view of poor response to the combination pharmacotherapy of escitalopram 20 mg daily, mirtazapine 30 mg daily, sodium valproate Chrono 500 mg daily, and quetiapine XR 400 mg daily, TRBD was diagnosed and a full course of ECT was given. However, the patient did not respond to ECT. Twenty sessions of CBT were then given in combination with pharmacotherapy and the patient achieved full functional recovery. Discussion: To date there is still a lack of consensus on both the diagnostic criteria of TRBD and the evidence based guideline for the treatment of TRBD. Adjunctive modafinil, pramipexole, tranylcypromine, and vagus nerve stimulation have been tried but the response rate is variable. Family-focused treatment, group psychoeducation, and interpersonal and social rhythm therapy have been tried on bipolar depression but more study is still required for TRBD patients that failed to respond to ECT. In conclusion, combination of CBT and pharmacotherapy is worth a trial for TRBD patients who do not respond to ECT.