{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,7]],"date-time":"2026-10-07T07:18:57Z","timestamp":1791357537621,"version":"4.3.1"},"reference-count":46,"publisher":"MDPI AG","issue":"6","license":[{"start":{"date-parts":[[2024,6,3]],"date-time":"2024-06-03T00:00:00Z","timestamp":1717372800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medicina"],"abstract":"<jats:p>Background and Objectives: Options for treatment-resistant bipolar depression (TRBPD) are limited. Electroconvulsive therapy (ECT) has shown efficacy in TRBPD. However, the cognitive deficits and memory concerns associated with ECT are problematic for a significant number of patients. It remains unclear what the next step is for patients with TRBPD who fail ECT. Materials and Methods: In this case report, we present a patient with TRBPD who sequentially received 12 sessions of brief-pulse right unilateral ECT, 22 sessions of ketamine infusion at 0.5\u20130.75 mg\/kg for 40 min, and 39 sessions of deep repetitive transcranial magnetic stimulation (dTMS). Results: The patient had some benefit from ECT, but declined continuation of ECT due to memory concerns. The patient tolerated ketamine infusion well but had limited benefit. However, the patient responded well to acute treatment with dTMS and maintained relative stability for more than 2 years. Conclusions: This case suggests that patients with TRBPD who fail ECT and\/or ketamine infusion might benefit from dTMS.<\/jats:p>","DOI":"10.3390\/medicina60060936","type":"journal-article","created":{"date-parts":[[2024,6,3]],"date-time":"2024-06-03T12:19:46Z","timestamp":1717417186000},"page":"936","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":3,"title":["Role of Electroconvulsive Therapy, Ketamine Infusion, and Deep Repetitive Transcranial Magnetic Stimulation in Treatment-Resistant Bipolar Depression: A Case Report"],"prefix":"10.3390","volume":"60","author":[{"given":"Keming","family":"Gao","sequence":"first","affiliation":[{"name":"Mood Disorders Program, Department of Psychiatry, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA"},{"name":"School of Medicine, Case Western Reserve University, Cleveland, OH 44106, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2024,6,3]]},"reference":[{"key":"ref_1","first-page":"23","article-title":"When at first you don\u2019t succeed: Sequential strategies for antidepressant nonresponders","volume":"58","author":"Thase","year":"1997","journal-title":"J. Clin. Psychiatry"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"649","DOI":"10.1016\/S0006-3223(03)00231-2","article-title":"Diagnosis and definition of treatment-resistant depression","volume":"53","author":"Fava","year":"2003","journal-title":"Biol. Psychiatry"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"125","DOI":"10.1016\/j.jpsychires.2019.03.021","article-title":"The assessment of resistance to antidepressant treatment: Rationale for the Antidepressant Treatment History Form: Short Form (ATHF-SF)","volume":"113","author":"Sackeim","year":"2019","journal-title":"J. Psychiatr. Res."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"230","DOI":"10.1093\/ijnp\/pyz064","article-title":"The CINP Guidelines on the Definition and Evidence-Based Interventions for Treatment-Resistant Bipolar Disorder","volume":"23","author":"Fountoulakis","year":"2020","journal-title":"Int. J. Neuropsychopharmacol."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"309","DOI":"10.1192\/bjp.2019.36","article-title":"Treatment-resistant and Multi-therapy resistant criteria for bipolar depression: Consensus definition\u2014CORRIGENDUM","volume":"214","author":"Berk","year":"2019","journal-title":"Br. J. Psychiatry"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"429","DOI":"10.1111\/j.1600-0447.2009.01471.x","article-title":"Treatment-resistant bipolar depression: Towards a new definition","volume":"120","author":"Pacchiarotti","year":"2009","journal-title":"Acta Psychiatr. Scand."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"691","DOI":"10.1111\/j.1399-5618.2010.00868.x","article-title":"Neurosurgical treatment of bipolar depression: Defining treatment resistance and identifying surgical targets","volume":"12","author":"Lipsman","year":"2010","journal-title":"Bipolar Disord."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"20451253231202723","DOI":"10.1177\/20451253231202723","article-title":"Ketamine for bipolar depression: An updated systematic review","volume":"13","author":"Fancy","year":"2023","journal-title":"Ther. Adv. Psychopharmacol."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"99","DOI":"10.1111\/bdi.13284","article-title":"Real-world effectiveness of repeated ketamine infusions for treatment-resistant bipolar depression","volume":"25","author":"Fancy","year":"2023","journal-title":"Bipolar Disord."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"e01805","DOI":"10.1002\/brb3.1805","article-title":"A retrospective analysis of bipolar depression treated with transcranial magnetic stimulation","volume":"10","author":"Goldwaser","year":"2020","journal-title":"Brain Behav."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"1079","DOI":"10.1001\/archpsyc.60.11.1079","article-title":"Efficacy of olanzapine and olanzapine-fluoxetine combination in the treatment of bipolar I depression","volume":"60","author":"Tohen","year":"2003","journal-title":"Arch. Gen. Psychiatry"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"527","DOI":"10.1111\/acps.12712","article-title":"Dopaminergic agents in the treatment of bipolar depression: A systematic review and meta-analysis","volume":"135","author":"Szmulewicz","year":"2017","journal-title":"Acta Psychiatr. Scand."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"97","DOI":"10.1111\/bdi.12609","article-title":"Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder","volume":"20","author":"Yatham","year":"2018","journal-title":"Bipolar Disord."},{"key":"ref_14","doi-asserted-by":"crossref","unstructured":"Yildiz, A., Ruiz, P., and Nemeroff, C. (2015). Bipolar Book: History, Neurobiology, and Treatment, Oxford University Press.","DOI":"10.1093\/med\/9780199300532.001.0001"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"31","DOI":"10.1016\/S2215-0366(15)00450-2","article-title":"Comparative evaluation of quetiapine plus lamotrigine combination versus quetiapine monotherapy (and folic acid versus placebo) in bipolar depression (CEQUEL): A 2 \u00d7 2 factorial randomised trial","volume":"3","author":"Geddes","year":"2016","journal-title":"Lancet Psychiatry"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"146","DOI":"10.1111\/j.1399-5618.2012.00997.x","article-title":"Efficacy of electroconvulsive therapy in bipolar versus unipolar major depression: A meta-analysis","volume":"14","author":"Dierckx","year":"2012","journal-title":"Bipolar Disord."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"41","DOI":"10.1176\/appi.ajp.2014.13111517","article-title":"Treatment-resistant bipolar depression: A randomized controlled trial of electroconvulsive therapy versus algorithm-based pharmacological treatment","volume":"172","author":"Schoeyen","year":"2015","journal-title":"Am. J. Psychiatry"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"226","DOI":"10.1192\/bjp.bp.109.066183","article-title":"Bifrontal, bitemporal and right unilateral electrode placement in ECT: Randomised trial","volume":"196","author":"Kellner","year":"2010","journal-title":"Br. J. Psychiatry"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"S25","DOI":"10.1016\/j.jagp.2021.01.018","article-title":"A Case of Successful Ketamine Treatment after ECT Failure in a patient with Major Depressive Disorder","volume":"29","author":"Chatham","year":"2021","journal-title":"Am. J. Geriatr. Psychiatry"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"491","DOI":"10.1016\/j.brs.2017.01.433","article-title":"Ketamine infusions after failure to respond to electroconvulsive therapy: A case series report","volume":"10","author":"McDonald","year":"2017","journal-title":"Brain Stimul."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"939","DOI":"10.1016\/j.biopsych.2011.12.010","article-title":"Replication of ketamine\u2019s antidepressant efficacy in bipolar depression: A randomized controlled add-on trial","volume":"71","author":"Zarate","year":"2012","journal-title":"Biol. Psychiatry"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"e01674","DOI":"10.1002\/brb3.1674","article-title":"Transient effects of multi-infusion ketamine augmentation on treatment-resistant depressive symptoms in patients with treatment-resistant bipolar depression\u2014An open-label three-week pilot study","volume":"10","author":"Zhuo","year":"2020","journal-title":"Brain Behav."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"38","DOI":"10.1016\/j.jad.2020.06.020","article-title":"A preliminary study of adjunctive ketamine for treatment-resistant bipolar depression","volume":"275","author":"Zheng","year":"2020","journal-title":"J. Affect. Disord."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"250","DOI":"10.1016\/j.jad.2020.10.013","article-title":"The efficacy of repetitive transcranial magnetic stimulation (rTMS) for bipolar depression: A systematic review and meta-analysis","volume":"279","author":"Nguyen","year":"2021","journal-title":"J. Affect. Disord."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"2045125320973790","DOI":"10.1177\/2045125320973790","article-title":"Repetitive Transcranial Magnetic Stimulation in the Treatment of Bipolar Disorder","volume":"10","author":"Hett","year":"2020","journal-title":"Ther. Adv. Psychopharmacol."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"211","DOI":"10.1016\/j.brs.2009.12.001","article-title":"Response to deep TMS in depressive patients with previous electroconvulsive treatment","volume":"3","author":"Rosenberg","year":"2010","journal-title":"Brain Stimul."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"2593","DOI":"10.1038\/npp.2017.26","article-title":"Treatment of Bipolar Depression with Deep TMS: Results from a Double-Blind, Randomized, Parallel Group, Sham-Controlled Clinical Trial","volume":"42","author":"Tavares","year":"2017","journal-title":"Neuropsychopharmacology"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"64","DOI":"10.1002\/wps.20199","article-title":"Efficacy and safety of deep transcranial magnetic stimulation for major depression: A prospective multicenter randomized controlled trial","volume":"14","author":"Levkovitz","year":"2015","journal-title":"World Psychiatry"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"336","DOI":"10.1016\/j.brs.2016.03.010","article-title":"The Clinical TMS Society Consensus Review and Treatment Recommendations for TMS Therapy for Major Depressive Disorder","volume":"9","author":"Perera","year":"2016","journal-title":"Brain Stimul."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"22ac14436","DOI":"10.4088\/JCP.22ac14436","article-title":"Prioritizing Patient Preferences: A Practical Guide for Tailoring Treatment Choices in Interventional Psychiatry","volume":"83","author":"Berman","year":"2022","journal-title":"J. Clin. Psychiatry"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"393","DOI":"10.1111\/ner.13046","article-title":"Effect of Previous Electroconvulsive Therapy on Subsequent Response to Transcranial Magnetic Stimulation for Major Depressive Disorder","volume":"23","author":"Yuan","year":"2020","journal-title":"Neuromodulation"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"106","DOI":"10.1097\/YCT.0b013e31827a70ba","article-title":"Transcranial magnetic stimulation maintenance as a substitute for maintenance electroconvulsive therapy: A case series","volume":"29","author":"Cristancho","year":"2013","journal-title":"J. ECT"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"73","DOI":"10.3389\/fpsyt.2013.00073","article-title":"Repetitive transcranial magnetic stimulation to maintain treatment response to electroconvulsive therapy in depression: A case series","volume":"4","author":"Noda","year":"2013","journal-title":"Front. Psychiatry"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"2315","DOI":"10.1056\/NEJMoa2302399","article-title":"Ketamine versus ECT for Nonpsychotic Treatment-Resistant Major Depression","volume":"388","author":"Anand","year":"2023","journal-title":"N. Engl. J. Med."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"339","DOI":"10.1093\/ijnp\/pyab088","article-title":"Racemic Ketamine as an Alternative to Electroconvulsive Therapy for Unipolar Depression: A Randomized, Open-Label, Non-Inferiority Trial (KetECT)","volume":"25","author":"Ekstrand","year":"2022","journal-title":"Int. J. Neuropsychopharmacol."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"100400","DOI":"10.1016\/j.jadr.2022.100400","article-title":"Repeated intravenous esketamine treatment in patients with ECT-resistant major depressive disorder","volume":"10","author":"Brouwer","year":"2022","journal-title":"J. Affect. Disord. Rep."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"755","DOI":"10.1017\/S1461145712000806","article-title":"Speed of response in ultrabrief and brief pulse width right unilateral ECT","volume":"16","author":"Loo","year":"2013","journal-title":"Int. J. Neuropsychopharmacol."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"831","DOI":"10.1007\/s00406-018-0925-z","article-title":"Brief vs. ultrabrief pulse ECT: Focus on seizure quality","volume":"268","author":"Brunner","year":"2018","journal-title":"Eur. Arch. Psychiatry Clin. Neurosci."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"e1092-8","DOI":"10.4088\/JCP.14r09145","article-title":"A Systematic Review and Meta-Analysis of Brief Versus Ultrabrief Right Unilateral Electroconvulsive Therapy for Depression","volume":"76","author":"Tor","year":"2015","journal-title":"J. Clin. Psychiatry"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"986378","DOI":"10.3389\/fpsyt.2022.986378","article-title":"Transcranial magnetic stimulation and intravenous ketamine combination therapy for treatment-resistant bipolar depression: A case report","volume":"13","author":"Elkrief","year":"2022","journal-title":"Front. Psychiatry"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"1267647","DOI":"10.3389\/fnins.2023.1267647","article-title":"Transcranial magnetic stimulation and ketamine: Implications for combined treatment in depression","volume":"17","author":"Kownacka","year":"2023","journal-title":"Front. Neurosci."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"297","DOI":"10.1089\/cap.2023.29245.bjc","article-title":"Ketamine and Transcranial Magnetic Stimulation in an Adolescent with Treatment-Resistant Depression","volume":"33","author":"Jerath","year":"2023","journal-title":"J. Child. Adolesc. Psychopharmacol."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"18","DOI":"10.1016\/j.jad.2023.04.019","article-title":"Intravenous ketamine for treatment-resistant depression patients who have failed to respond to transcranial magnetic stimulation: A case series","volume":"333","author":"Payette","year":"2023","journal-title":"J. Affect. Disord."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"614","DOI":"10.1002\/da.22060","article-title":"Efficacy and acceptability of high frequency repetitive transcranial magnetic stimulation (rTMS) versus electroconvulsive therapy (ECT) for major depression: A systematic review and meta-analysis of randomized trials","volume":"30","author":"Berlim","year":"2013","journal-title":"Depress. Anxiety"},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"l1079","DOI":"10.1136\/bmj.l1079","article-title":"Comparative efficacy and acceptability of non-surgical brain stimulation for the acute treatment of major depressive episodes in adults: Systematic review and network meta-analysis","volume":"364","author":"Mutz","year":"2019","journal-title":"BMJ"},{"key":"ref_46","doi-asserted-by":"crossref","unstructured":"Strandberg, P., Nordenskj\u00f6ld, A., Bod\u00e9n, R., Ekman, C.J., Lundberg, J., and Popiolek, K. (J. ECT, 2023). Electroconvulsive Therapy Versus Repetitive Transcranial Magnetic Stimulation in Patients with a Depressive Episode: A Register-Based Study, J. ECT, online ahead of print.","DOI":"10.1097\/YCT.0000000000000971"}],"container-title":["Medicina"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1648-9144\/60\/6\/936\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T14:52:50Z","timestamp":1760107970000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1648-9144\/60\/6\/936"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,6,3]]},"references-count":46,"journal-issue":{"issue":"6","published-online":{"date-parts":[[2024,6]]}},"alternative-id":["medicina60060936"],"URL":"https:\/\/doi.org\/10.3390\/medicina60060936","relation":{},"ISSN":["1648-9144"],"issn-type":[{"value":"1648-9144","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,6,3]]}}}