4th Edition of Psychiatry and Addiction World Conference 2026

Abstract

Introduction/Background Ultra-rapid cycling bipolar disorder, characterized by mood episodes occurring over days to weeks, represents a severe and less well-characterized variant of rapid cycling, which is defined as four or more mood episodes per year1,2. Clinical management is particularly challenging as the condition may become refractory and can be exacerbated by antidepressant use.1,3 Limited data exists regarding long-term treatment strategies for ultrarapid cycling bipolar disorder. We present a case highlighting longitudinal symptom variability and response to multiple treatment modalities, with efforts to balance efficacy and tolerability.
Case Description We present the case of a 51-year-old female with a history of ultra-rapid cycling bipolar disorder, diagnosed in 2018, two years after an initial diagnosis of bipolar disorder. Her psychiatric history is significant for more than 10 prior suicide attempts by overdose. Between 2023 and April 2026, she underwent multiple pharmacologic and procedural interventions, with Patient Health Questionnaire-9 (PHQ-9) scores ranging from 9–24 and Generalized Anxiety Disorder-7 (GAD-7) scores ranging from 6–26. Prior to 2023, she was treated with mood stabilizers including divalproex sodium and lamotrigine, which were discontinued due to adverse effects, including weight gain and elevated liver function tests exacerbated by the patients’ alcohol use disorder. Lithium was initiated in October 2024 and has been continued, with stable serum levels and good tolerability. 2 Several second-generation (atypical) antipsychotics, including olanzapine, quetiapine, lurasidone, lumateperone, and cariprazine, were trialed and discontinued due to either lack of efficacy or adverse effects. Electroconvulsive therapy (ECT) was started in July 2024 for two cycles, with partial improvement. ECT was then discontinued following the two cycles due to logistical challenges as well as the patients’ recovery difficulties. Clozapine was initiated in July 2025 and titrated to 300 mg daily, resulting in improvement in mood and psychotic symptoms (Figure 1). However, it was discontinued in March 2026 due to side effects, including sialorrhea and weight gain. Oral aripiprazole 30 mg daily was initiated in March 2026 and transitioned to a long-acting injectable formulation (400 mg monthly), with improved adherence and tolerability. Current medications include lithium 600 mg in the morning and 300mg at bedtime, aripiprazole 400 mg monthly (long-acting injectable), buspirone 20 mg three times daily, and hydroxyzine 25 mg twice daily as needed for anxiety. Duloxetine is being tapered and discontinued, and a short course of doxepin (25 to 50 mg at bedtime) was prescribed for insomnia. Despite these interventions, the patient continues to experience ultra-rapid cycling mood episodes and intermittent auditory hallucinations.