Cases That Test Your Skills

Psychotic and in pain

Current Psychiatry. 2012 April;11(4):64-69

References

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2. Ferroli P, Fioravanti A, Schiariti M, et al. Microvascular decompression for glossopharyngeal neuralgia: a long-term retrospective review of the Milan-Bologna experience in 31 consecutive cases. Acta Neurochir (Wien). 2009;151(10):1245-1250.

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Depression, psychosis, and pain

From the beginning of Mrs. P’s treatment, we considered psychotic depression worsened—if not completely explained—her pain. Her somatic complaints appeared to be subtly woven into her delusional constructs. For instance, she complained that a device had been implanted in her head and she had the scar to prove it, pointing to the scar from her microvascular decompression surgery. Research indicates that depressive illness and chronic pain syndromes are highly comorbid and depressive illness can worsen pain syndromes.^6,7 In addition, Mrs. P failed several medical and 1 surgical interventions for her pain condition that had high success rates. Her husband notes that when her outpatient psychiatrist started olanzapine 3 months ago for emerging psychotic symptoms, her pain complaints initially decreased with her psychotic symptoms, and she used less opiate medication during that time. Several months later Mrs. P’s pain complaints increased as her psychotic symptoms worsened. Second-generation antipsychotics have been evaluated as treatment for chronic pain syndromes, and may exert a primary analgesic effect.^8,9 However, because of the correlation between her fluctuating psychotic symptoms and pain complaints, the more plausible explanation for olanzapine’s initial efficacy in treating Mrs. P’s pain is a secondary analgesic effect from decreased psychotic somatic preoccupation.

Clinical Point

Depressive illness and chronic pain are highly comorbid and depressive illness can worsen pain syndromes

TREATMENT: ECT

Mrs. P is admitted to the inpatient psychiatric unit and placed on suicide precautions. Oxycodone/acetaminophen and clonazepam are tapered and limited to twice daily as needed. Escitalopram is tapered and discontinued. Thiothixene is tapered and replaced by olanzapine, 5 mg/d. Mrs. P receives 3 bifrontal, brief pulse-width ECT treatments. These result in marked improvement in her depressive and psychotic symptoms. In addition, her pain complaints become minimal. She becomes less preoccupied with her sexual trauma and grows to trust many staff members whom she previously believed were part of her traumatic childhood events. Mrs. P is no longer suicidal and asks to continue ECT treatments as an outpatient. She is discharged on olanzapine, 5 mg/d, trazodone, 100 mg/d for insomnia, benztropine, 2 mg/d, clonazepam 0.5 mg twice daily as needed for panic attacks, and oxycodone/acetaminophen, 5 mg/325 mg twice daily as needed for pain.

The authors’ observations

According to the Harvard South Shore Algorithm, treatment strategies for psychotic depression include antidepressant and antipsychotic combinations, lithium augmentation, clozapine, and ECT.¹⁰ Several factors made ECT the best option for Mrs. P. She had failed multiple treatment strategies and was suicidal. ECT is an effective treatment for MDD with psychotic features, single or recurrent episode.¹¹ ECT can be used as a primary treatment before psychotropic medications or secondarily when there has been lack of clinical response to medications, intolerable side effects, deterioration in psychiatric condition, or suicidality.^11,12 In addition, when treated with ECT, psychotic depression has a significantly higher remission rate than major depression without psychosis.¹² Delusional guilt, psychomotor retardation, hypochondriacal preoccupations, loss of insight, paranoia, and obsessive-compulsive symptoms predict a favorable response.¹² ECT also has demonstrated efficacy for treating pain secondary to psychotic depression or melancholic depression.¹³ In addition, ECT has been shown to have analgesic properties beyond treating underlying depression.¹⁴ Our primary focus was not to treat Mrs. P’s pain syndrome with ECT; however, in treating her psychotic depression we had hoped that her pain tolerance would improve and she would rely less on opiates.

Clinical Point

Treatment strategies for psychotic depression include antidepressants, antipsychotics, lithium augmentation, clozapine, and ECT

OUTCOME: Pain relief

As an outpatient, Mrs. P receives 11 bifrontal ECT treatments in her initial series, followed by 7 bifrontal maintenance treatments. Her speech is more spontaneous, her grooming and hygiene improve, and she exhibits a brighter and more reactive affect. Suicidal ideation has resolved. Pain improves from a “10 out of 10” to a “2 out of 10.” Mrs. P consistently requires less oxycodone/acetaminophen. She relates better to her family and begins exploring new hobbies such as pottery. In addition to monthly maintenance bifrontal ECT treatments, she is stable on citalopram, 60 mg/d, and trazodone, 50 mg/d as needed for insomnia.

Clinical Point

ECT has demonstrated efficacy for treating pain secondary to psychotic depression or melancholic depression

The authors’ observations

The relationship between depressive illness and chronic pain is complex. Treating a primary depressive illness can lead to improved functional outcomes and decreased disability from chronic pain complaints.¹⁵ Patients with comorbid chronic pain and depressive illness are more likely to suffer from unremitting pain despite compliance with evidence-based treatment strategies.¹⁶ Mrs. P had 2 co-occurring disorders: psychotic depression and chronic pain disorder secondary to glossopharyngeal neuralgia. Our opinion is that Mrs. P’s psychotic depression worsened her experience of pain.