A 10-Week Memantine Treatment in Bipolar Depression: A Case Report. Focus on Depressive Symptomatology, Cognitive Parameters and Quality of Life
A 49-year-old male with the diagnosis of type I BD, treated psychiatrically for over 20 years, previously 5 times hospitalized, was admitted in a manic episode, when he tried to force the hospital door. During the first 2 weeks of olanzapine treatment the manic symptoms have been reduced. After the manic episode ended, some depressive symptoms emerged, quickly reaching a moderate severity. Continuing the therapy with lithium (1 g/day) and olanzapine (7.5 mg/day) for several weeks we have not noted any significant improvement. Treatment with mianserin, an alpha adrenergic antidepressant characterized by a low switch risk was started. After 6 weeks of mianserin (initially at 30 mg/day for 3 weeks, then raised to 60 mg/day) there was still no clinical improvement. After obtaining an informed consent, the patient started the intake of memantine with no other changes of the treatment. For the first week the daily memantine dose was 5 mg, every week it was increased by 5 mg to a maximum of 20 mg. Tolerance of the drug throughout its use was very good, the patient did not report any side effects whatsoever.\nThe patient had no other chronic illness than BD. Neurological assessments showed no abnormalities; the hematological, biochemical and hormonal (TSH) parameters were normal. In the CT scan no significant morphological changes were found.\nEvery week during the10 weeks of memantine treatment and also 6 weeks after its termination the patient was examined using the Hamilton Depression Rating Scale (HDRS), Young Mania Rating Scale (YMRS), Hamilton Anxiety Scale (HAMA), Clinical Global Impression (CGI) and World Health Organization Quality of Life Scale (WHOQOL-BREF - short version, ). Before starting memantine (week 0-W0) and at the end of its use (W10) the patient also performed psychological examination panel ().\nAfter the memantine initiation we observed a consecutive improvement of depressive symptoms, which was noted early, what is congruent with the observations of Anand et al. We noted a significant improvement in mood, sleep parameters and appetite. After a quick improvement following first doses of memantine the level of anxiety remained on the same mild level. During the memantine period a brief mild depressive exacerbation was observed (ca. W5), which was conditioned by objective external circumstances, but with this exception the mood was quite stable and the patient gradually improved.\nIn depressive, hypomanic or manic but also euthymic bipolar patients the cognitive functioning is significantly worse than in normal population., Assessing the progress in the treatment we compared the performance results of such functions as attention [Wisconsin Card Sorting Test (WCST), d2 test], direct visual memory [Benton Visual Retention Test (BVRT) - method A, versions C and D], direct auditory memory (repeating digits directly) and operational memory (WCST, repeating digits backwards), visuo-spatial working memory [WCST, Trail Making Test (TMT) - Part B], psychomotor speed (TMT - Part A), language and communication functions of the right hemisphere [The Right Hemisphere Language Battery, polish version (RHLB-PL)], auditory verbal learning [Auditory-Visual Learning Test (AVLT) - with two alternative versions], verbal fluency (semantic: animals, fruits and phonemic: letters K and S) and executive functions [Ruff Figural Fluency Test (RFFT), TMT - Part B].\nCognitive functioning results before and after the treatment indicate a marked improvement in auditory verbal learning, accuracy of verbal material learning and reduction of susceptibility to distraction. The numerical parameters of concentration, perceptual speed and accuracy of work also improved.\nThe overall result of right hemisphere language functions and communication skills, direct auditory and operating memory and psychomotor speed remained on similar levels before and after the memantine treatment.\nThe results of direct visual memory tests are difficult to comment. The numerical parameters (the number of wrong and right answers) were slightly worse in the second assessment, however, despite the alternative version of the test, it cannot be regarded as equivalent in terms of psychometric properties. The WCST results were slightly worse on the second assessment.\nThe numerical parameters (both semantic and phonemic) of verbal fluency in both assessments were similar.\nIn the RFFT and TMT (Part B) tests, assessing - among others - executive functions, a qualitative improvement in the efficiency of planning (the use of a rotation strategy in RFFT) and also in the control of action (error-free switching of the TMT) was observed. This improvement may be partly explained by the learning effect.\nQuality of life was assessed using the popular WHOQOL-BREF (). Parallelly to the clinical improvement, we also noted better quality of life parameters in the items describing physical functioning - e.g., sleep, energy, treatment, pain (part 1) and environment - finances, health services, living place (part 4).\nDue to persistent mild depressive symptoms with a relatively excessive drive reduction, memantine and mianserin were stopped and venlafaxine was started (up to 75 mg per day). This resulted in a satisfactory drive improvement and remission of the depression without any manic symptoms for 3 weeks (weeks 11-15 in ).