Adjunctive vagus nerve stimulation for treatment-resistant bipolar disorder: Managing device failure or the end of battery life

The vagus nerve stimulation (VNS) device is used not only to treat refractory seizure disorders but also mood disorders; the latter indication received CE Mark approval in 2001 and Food and Drug Administration approval in 2005. Original estimates for the end of battery life (EOBL) were approximately 6-10 years. Many neuropsychiatric patients have or will soon face EOBL. A patient with severe, life-threatening, treatment-resistant bipolar disorder underwent 9 years of stable remission following 20 months of adjunctive VNS. The device ceased operation at EOBL. Because of logistical issues, re-initiation of VNS was delayed over several months. The patient relapsed with depression, mania and mixed states, and regained remission 17 months after device replacement. This case dictates prudence in managing stable patients in remission with VNS. If the device malfunctions, urgent surgical replacement is warranted with subsequent rapid titration to previous parameters as tolerated. Several months' delay may trigger relapse and prove difficult to re-establish remission.