Author Affiliations:

Dr. Lantz is Chief of Geriatric Psychiatry, Beth Israel Medical Center, First Ave @ 16th Street #6K40, New York, NY 10003; (212) 420-2457; fax: (212) 844-7659;
e-mail: mlantz@chpnet.org.

Case Presentation

Mrs. P is a 72-year-old widowed African-American woman who is admitted to the medical service of a hospital due to dehydration, weight loss, and lethargy. She has a history of breast cancer treated with surgery and radiation 5 years ago. Her primary care physician is concerned that she may be suffering from a recurrence of cancer. Mrs. P undergoes a full medical evaluation with multiple consultations with an oncologist, gastroenterologist, and neurologist. Her lethargy improves with intravenous hydration, but her oral intake is poor. She complains that food doesn’t taste good and is reluctant to get out of bed to sit in a chair. A physical therapy evaluation finds that she is capable of standing and walking, but displays poor motivation. A psychiatric consultation is requested after all of Mrs. P’s medical tests are negative for malignancy. The patient has lost almost 40 pounds in the past year. She suffers from osteoarthritis and was functioning independently until she became increasingly depressed over the past 6-8 months.

The psychiatrist finds that Mrs. P displays feelings of hopelessness and helplessness with delusional beliefs that she cannot eat due to her food being stuck inside her stomach. She displays a tearful affect and ruminates about being a burden on her son and daughter-in-law. Mrs. P reports that she was treated in the past for depression after she was diagnosed with breast cancer and took a medication for several months. She cannot recall any details of her psychiatric treatment but is able to give the psychiatrist the telephone number of her son. Mrs. P requires a great deal of encouragement, but is able to give the correct date and to recall recent events. She agrees to take psychiatric medication but refuses admission to the inpatient psychiatry unit, requesting instead to go home.

Mrs. P is unable to care for herself, refusing meals due to her delusional beliefs, and displays depression with severe hopelessness and helplessness. She is admitted involuntarily to the hospital inpatient psychiatric unit for treatment of major depressive disorder with psychotic features. Her son is an Army medic who is home on leave but will return to Iraq in two weeks. Mr. P reports to the psychiatrist that he recalls his mother being treated with venlafaxine in the past. He requests that his mother be given any medications needed to stabilize her condition, but reports that the does not want her to receive “electric shock or any other type of memory-altering treatment.” The psychiatrist explains to him that his mother is willing to take medication and discusses options for treatment. Given the severity of her depression and presence of psychotic symptoms, she is a candidate for electroconvulsive therapy (ECT) but may respond well to a trial of medication.

Mrs. P is started on venlafaxine 75 mg daily for depression and olanzapine 5 mg for psychotic symptoms. Over the next 2 weeks the venlafaxine dose is titrated to 225 mg daily and olanzapine to 15 mg at bedtime. While Mrs. P becomes more ambulatory, she continues to appear depressed and focused on delusions of being unable to eat solid food. She drinks liquid nutritional supplements and gains 2 pounds. Her self-care remains poor, and she continues to require assistance in order to bathe or dress. A family meeting is held with Mrs. P and her son before he returns to Iraq. Due to the patient’s severe depression with psychotic symptoms, ECT is again discussed as a treatment option. Mr. P remains adamant that he would rather see his mother in a nursing home than “have her brain fried.”

Mrs. P remains in the hospital for another 2 weeks. She continues to appear depressed. The venlafaxine dose is increased to 300 mg daily, and olanzapine is increased to 20 mg at bedtime. There is marginal improvement in her delusions and mood. Olanzapine is switched to risperidone 1 mg twice daily, and lithium carbonate 300 mg twice daily is added to augment the antidepressant effect of venlafaxine. Her lithium level is 0.8 mEq/L. Mrs. P continues to refuse most meals and drinks liquid supplements. Her mood remains depressed and she is unable to care for herself. After 8 weeks of hospitalization she has displayed very limited improvement. The option of ECT is again discussed with Mrs. P. She explains that she wants to get better but that her son told her that ECT would “destroy her brain.” The psychiatrist and staff do not want to see Mrs. P remain depressed or require chronic care for a treatable condition. Consideration is given to applying for a court order for treatment over objection.

Discussion

ECT remains one of the most effective treatments for major depressive disorder, particularly if the condition is severe or accompanied by psychotic symptoms.1 ECT is also effective in the treatment of nonpsychotic depression, bipolar disorder, catatonia, intractable seizures, Parkinson’s disease, and other conditions (Table I).1-3 ECT offers a safe and potentially rapid response to conditions that may be life-threatening in cases where the risk of suicide and severe self-neglect is high.2 It is often utilized when medications fail or response to other therapies is partial or limited. Most patients who receive ECT are severely ill and hospitalized when the treatment is considered.2,3

ECT is probably one of the most maligned and misunderstood treatments in psychiatry. In part, this is due to the early use in the 1930s of chemical agents such as camphor and pentylenetetrazol to induce seizures that were often uncontrolled. Later in 1938, electricity to induce seizures was introduced, without the benefit of modern-day anesthesia or monitoring techniques.1 ECT was also confused with other primitive treatments, including the induction of coma with insulin, which was eventually proven to be ineffective.1,2

The current practice of ECT is well monitored and well controlled, utilizing evidence-based techniques and the benefits of modern anesthesiology to maximize patient comfort and outcomes. Treatment is typically given 2 to 3 times per week during the acute phase, with the availability of outpatient ECT for ongoing continuation and maintenance therapy.3,4 A great deal of the stigma associated with ECT concerns its side effects of short-term confusion and memory loss, which typically are time-limited.5 Other known risks associated with ECT include cardiac arrhythmias, prolonged seizures, apnea requiring intubation, and, more commonly, headaches, muscles aches, and dental pain.2

ECT involves the administration of an electric stimulus to induce a seizure of at least 25 to 30 seconds in duration through electrodes applied to the patient’s head.1,2 The patient is given sedation with a short-acting barbiturate, propofol or etomidate, and a paralytic agent such as succinylcholine by an anesthesiologist prior to delivery of the stimulus. Physiologic monitoring including cardiac rhythm, blood pressure, oxygen saturation, electroencephalogram, and motor signs of seizure (through the use of a blood pressure cuff applied to one extremity) are standard during the procedure.2,3 The electrical stimulus delivered varies greatly from patient to patient based on individual seizure threshold, and is typically calculated based on age, gender, concurrent medications, and prior treatment response. In most hospitals ECT is given 3 times per week.1,2

ECT may be delivered using unilateral electrode placement over the right temporal area and back of the head, referred to as right unilateral, or bitemporal electrode placement, known as bilateral ECT. While right unilateral therapy may offer the advantage of fewer side effects, particularly less memory loss and confusion, there is also evidence that bilateral ECT may be more effective. Clinicians often start with right unilateral ECT with the option of switching to bilateral if the patient does not display sufficient improvement.1-3 During the treatment, an electrical stimulus measured in millicoulombs is delivered through a brief pulse mechanism to induce the seizure. During the induced seizure, the patient’s heart rate initially drops, then increases. Blood pressure increases during the seizure and returns to baseline.2-4 Patients with a history of hypertension may require an adjustment in antihypertensive medications prior to each treatment to control blood pressure. As ECT actually produces a protective effect against seizures, the length of the seizure typically decreases over the course of multiple treatments.2-4

Prior to ECT, patients should undergo a thorough history, psychiatric evaluation to clarify diagnosis, medical assessment, and basic tests including complete blood count, chemistry panel, urinalysis, electrocardiogram, chest x-ray, and, if indicated, urine toxicology.2 Medications that may interfere with ECT, such as lithium, theophylline, lidocaine, benzodiazepines, and anticonvulsants, should be discontinued or adjusted (Table II).2,3 Many physicians will eliminate or reduce the dose of antidepressant agents during ECT. During the course of ECT the patient should be monitored for signs of memory loss and confusion that persist beyond the day of treatment. This may indicate a need to reduce the number of treatments per week from 3 to 2, or to hold ECT until the confusion improves.5

There are no absolute contraindications to ECT, although conditions such as recent myocardial infarction, intracranial space-occupying lesion, unstable cardiovascular disease, severe pulmonary disease, or high anesthesia risk will require maximizing the patient’s medical status prior to treatment.2 Age is not a contraindication; older adults receive more than one-third of ECT provided in the United States, a greater percentage than those younger than 65 years. Many elderly patients have received ECT in the past with good effect and choose this treatment selectively over medication if needed.6

A course of ECT for acute treatment may involve 6-12 treatments. Following acute treatment, continuation of ECT as an outpatient or medication may be used to sustain remission. If medication is not utilized, maintenance ECT should be considered to prevent relapse.3,4 Rate of treatment response for ECT is as high as 80% to 90%, but relapse rates approach 50% within the first year if medication or maintenance treatment is not provided.7 For patients who are treatment-refractory to medications, maintenance ECT provided on a graduated schedule of weekly to biweekly to monthly has been effective in achieving stable remission.7,8 Patients with high-risk conditions may require an overnight hospital stay for maintenance ECT. Others may choose to have ECT on an outpatient basis, similar to the model of same-day surgery.2
Information for patients and family members about the treatment of depression with ECT may be downloaded from the American Academy of Family Physicians website (familydoctor.org) and the Mayo Clinic website (www.mayoclinic.com).

Outcome of the Case Patient

Mrs. P remained in the hospital for 8 weeks, with only a marginal response to medication therapy. The treatment team felt that she may be more receptive to a discussion of ECT due to her desire to return home. The psychiatrist, social worker, and nurse met with Mrs. P to discuss her treatment options. She expressed feeling tired and hopeless about her inability to eat food. Mrs. P admitted that she would be unable to manage if she left the hospital and was willing to watch a DVD about ECT. After watching the treatment being given safely and hearing other patients discuss their positive responses, Mrs. P was willing to give the treatment a chance. The risks and benefits were discussed with her, and she gave her consent. Lithium therapy was discontinued in preparation for ECT, and the dose of venlafaxine was reduced. Risperidone was continued. After the first ECT, Mrs. P recovered well but felt frustrated by not feeling any better. She was encouraged to continue. After ECT #4, Mrs. P started appearing brighter and asked for breakfast after returning from the recovery room. Following ECT #6, Mrs. P appeared well-related and neatly dressed and groomed, and was asking to return home. She was discharged home after a 10-week hospital stay. She returned to the hospital to receive 3 additional treatments as an outpatient and then continued to take venlafaxine and risperidone. At a 6-month follow-up visit Mrs. P was managing well independently with no recurrence of her mood or psychotic symptoms. Mrs. P still felt unable to discuss ECT with her family and asked that her son not be informed of her treatment.

The author reports no relevant financial relationships.