Cases That Test Your Skills

A 95-year-old man with treatment-resistant depression

Current Psychiatry. 2018 January;17(1):49-53

Mr. R, age 95, presents with depressive symptoms that began 6 weeks ago. He recently has lost 20 lb and is rapidly deteriorating. Which treatment would you recommend?

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References

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2. Dombrovski AY, Mulsant BH. The evidence for electroconvulsive therapy (ECT) in the treatment of severe late-life depression. ECT: the preferred treatment for severe depression in late life. Int Psychogeriatr. 2007;19(1):10-14,27-35; discussion 24-26.
3. Olfson M, Marcus S, Sackeim HA, et al. Use of ECT for the inpatient treatment of recurrent major depression. Am J Psychiatry. 1998;155(1):22-29.
4. Salzman C, Wong E, Wright BC. Drug and ECT treatment of depression in the elderly, 1996-2001: a literature review. Biol Psychiatry. 2002;52(3):265-284.
5. Kellner CH, Husain MM, Knapp RG, et al; CORE/PRIDE Work Group. A novel strategy for continuation ect in geriatric depression: phase 2 of the PRIDE study. Am J Psychiatry. 2016;173(11):1110-1118.
6. Tew JD Jr, Mulsant BH, Haskett RF, et al. Acute efficacy of ECT in the treatment of major depression in the old-old. Am J Psychiatry. 1999;156(12):1865-1870.
7. Dombrovski AY, Mulsant BH, Haskett RF, et al. Predictors of remission after electroconvulsive therapy in unipolar major depression. J Clin Psychiatry. 2005;66(8):1043-1049.
8. Charles K. UpToDate. Unipolar major depression in adults: indications for efficacy of electroconvulsive therapy (ECT). https://www.uptodate.com/contents/unipolar-major-depression-in-adults-indications-for-and-efficacy-of-electroconvulsive-therapy-ect. Updated May 16, 2017. Accessed November 26, 2017.
9. Sackeim HA, Prudic J, Devanand DP, et al. A prospective, randomized, double-blind comparison of bilateral and right unilateral electroconvulsive therapy at different stimulus intensities. Arch Gen Psychiatry. 2000;57(5):425-434.
10. UK ECT Review Group. Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis. Lancet. 2003;361(9360):799-808.
11. Lisanby SH. Electroconvulsive therapy for depression. N Engl J Med. 2007;357(19):1939-1945.
12. Stoppe A, Louzã M, Rosa M, et al. Fixed high dose electroconvulsive therapy in elderly with depression: a double-blind, randomized comparison of efficacy and tolerability between unilateral and bilateral electrode placement. J ECT. 2006;22(2):92-99.
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16. Philibert RA, Richards L, Lynch CF, et al. Effect of ECT on mortality and clinical outcome in geriatric unipolar depression. J Clin Psychiatry. 1995;56(9):390-394.
17. Tomac TA, Rummans TA, Pileggi TS, et al. Safety and efficacy of electroconvulsive therapy in patients over age 85. Am J Geriatr Psychiatry. 1997;5(2):126-130.
18. Verwijk E, Comijs HC, Kok RM, et al. Short and long-term neurocognitive functioning after electroconvulsive therapy in depressed elderly: a prospective naturalistic study. Int Psychogeriatr. 2014;26(2):315-324.
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CASE Depressed, avoidant

Mr. R, age 95, has a history of recurrent major depressive disorder. He presents to the emergency department with depressive symptoms that began 6 weeks ago. His symptoms include depressed mood, hopelessness, anhedonia, anxiety, and insomnia. Co-occurring anorexia nervosa has resulted in a 20-lb weight loss. He denies suicidal ideation.

A mental status examination reveals profound psychomotor agitation, dysphoric mood, tearfulness, and mood-congruent delusions. Mr. R’s Mini-Mental State Examination (MMSE) score is 14/30; his Hamilton Depression Rating Scale (HAM-D) score is 21, indicating severe depression (19 to 22). However, the examiner feels that these scores may not reflect an accurate assessment because Mr. R gave flippant responses and did not cooperate during the interview. Physical examination is unremarkable. Previous medication trials included buspirone, escitalopram, and risperidone; none of these medications successfully alleviated his depressive symptoms.

On admission, Mr. R is given oral mirtazapine, 15 mg/d, and quetiapine, 25 mg/d, to target depressive mood, insomnia, and weight loss. Urgent intervention is indicated because his depressive symptoms are profoundly causing failure to thrive and are compromising his physical health. Mr. R’s deterioration concerns the physician team. Because of a history of failed pharmacotherapy trials, the team reassesses Mr. R’s treatment options.

The authors’ observations

The physician team recommends that Mr. R undergo ECT to obtain rapid relief from his depressive symptoms. After discussion of the potential risks and benefits, Mr. R agrees to this treatment. Quetiapine is discontinued prior to initiating ECT to avoid unnecessary medications; mirtazapine is continued.

Mr. R’s lack of response to previous antidepressants and significant deterioration were concerning. The physicians wanted to avoid higher-dose medications because of the risk of falls or somnolence. Their clinical experience and the literature supporting ECT for patients of Mr. R’s age lead them to select ECT as the most appropriate therapeutic option.

ECT has no absolute contraindications.¹ The rate of ECT use in the United States has fluctuated over time because of factors unrelated to the efficacy and availability of ECT or alternative treatments.² This form of intervention is also somewhat stigmatized.

Some psychiatrists are reluctant to prescribe ECT for geriatric patients because of concerns of potential neurocognitive or medical complications and risks during anesthesia. However, in the United States, older patients with depression are more likely to be treated with ECT than their younger counterparts.³ ECT usually induces greater immediate efficacy than antidepressants.⁴

A 95-year-old man with treatment-resistant depression

References

CASE Depressed, avoidant

The authors’ observations

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