Neuromodulation therapies and ketamine in older age bipolar disorder

Abstract

Neuromodulation therapies are important alternatives for the management of treatment-resistant mood disorders in the elderly. Some of these therapies are relatively modern strategies such as the recently FDA-approved transcranial magnetic stimulation (TMS), vagal nerve stimulation (VNS), and deep brain stimulation (DBS), which is still undergoing extensive research. The use of electroconvulsive therapy (ECT) has evolved in its practice since the 1940s with a recent significant shift toward the use of right unilateral, ultra-brief-pulse width. Additionally, ECT is increasingly delivered in outpatient settings. The roles of the newer therapies have not been systematically studied in the geriatric population, and despite the fact that ECT has been widely used in the older population, there is limited evidence-based data about the use of ECT in the older adults. Older individuals are particularly vulnerable to polypharmacy given increasing medical comorbidity with advancing age. Neuromodulation techniques are not pharmacotherapies and, therefore, have the potential of limiting polypharmacy in older adults with psychiatric disorders. While the vast majority of neuromodulation therapy research focuses on unipolar depression, there is an increase in research examining the safety and efficacy of ECT for individuals with bipolar disorder. In this chapter, we will review the evidence-based data for electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), deep brain stimulation (DBS), transcranial direct current stimulation (tDCS), magnetic seizure therapy (MST), and focal electrically administered seizure therapy (FEAST) in older adults with psychiatric disorders. Relevant evidence for the use of ketamine during ECT and independent of ECT treatment will also be reviewed.