A. Rapid-cycling is often difficult to treat, as I indicate in response to the first question in this column. Please do not despair that no control will be found. Whereas ECT can be quite helpful for breaking a severe manic episode, there is much less evidence of its helpfulness as prophylaxis, even in complicated cases, much less severe ones such as yours. I would not think that continued ECT was advisable. I should add that where data are limited, such as is the case with ECT, opinions rather than evidence start to become stronger, and that there are psychiatrists who would take a more favorable view of maintenance ECT than my experience supports.
Alternatives are divalproex, clozapine, olanzapine, gabapentin, lamotrigine and carbamazepine.
It is best not to think of these as alternative flavors of ice cream, but as drugs with different properties and mechanisms, which may often be used more effectively in combination than alone. Only divalproex is used for bipolar disorder, but the others are approved for other indications and may generally be safely used. The rationale for the choice of one vs. another is beyond the reasonable length of my response here. Discuss this in detail with your psychiatrist. Clozapine, for example, has several side effects and risks that limit its frequency of use, despite evidence that its efficacy may be high.