Rosh Psychiatry Board Practice Exam

Which scenario best represents an indication for electroconvulsive therapy in bipolar I disorder?

1. Episode of mania with insomnia

2. Major depressive episode with malignant catatonia

3. Major depressive episode with suicidal ideation without a plan

4. Manic episode with severe flight of ideas

The correct answer is: Major depressive episode with malignant catatonia

Electroconvulsive therapy (ECT) is particularly indicated in severe and life-threatening conditions, where rapid response is necessary. In the context of bipolar I disorder, an episode characterized by malignant catatonia warrants immediate intervention due to the risk of severe complications and the urgency of treatment. Malignant catatonia is a severe neuropsychiatric condition that can lead to extreme autonomic instability, rigidity, and significant impairment. This condition often requires more aggressive treatment options than standard pharmacotherapy, as traditional medications may take time to take effect, and there is a risk of further deterioration. ECT is known for its rapid efficacy in increasing mood and resolving psychomotor agitation or catatonia, making it a crucial intervention in such scenarios. In contrast, while other options mention episodes of mania or depressive episodes, they do not carry the same immediate risk to life or urgency that malignant catatonia does. Therefore, option B represents the most appropriate indication for ECT among the given scenarios, as it emphasizes the necessity for swift and effective treatment to address a potentially critical situation in the patient's health.