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Let’s say that you’re managing a patient admitted with a manic episode who is not responding to lithium plus an antipsychotic, and there is no antidepressant around to blame or remove. You’ve already tried loading divalproex along with a different antipsychotic. Now, the patient is on lithium, divalproex, and olanzapine and is still sleeping only about 2 hours a night on your inpatient unit. You know what this is like. You’re under a lot of pressure from the inpatient unit staff to get this patient’s behavior under control. So, what are your options?
Well, electroconvulsive therapy (ECT) is an option, though considered as second- or third-line in most guidelines. The authors of a recent review in the American Journal of Psychiatry include Harold Sackeim, who has been studying ECT and is definitely a proponent, so you can hear advocacy in much of this review. The authors noted that ECT is
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