Cases That Test Your Skills

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

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

References

1. Kerner N, Prudic J. Current electroconvulsive therapy practice and research in the geriatric population. Neuropsychiatry (London). 2014;4(1):33-54.
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.
13. Geduldig ET, Kellner CH. Electroconvulsive therapy in the elderly: new findings in geriatric depression. Curr Psychiatry Rep. 2016;18(4):40.
14. Practice guideline for the treatment of patients with major depressive disorder (revision). American Psychiatric Association. Am J Psychiatry. 2000;157(suppl 4):1-45.
15. Rhebergen D, Huisman A, Bouckaert F, et al. Older age is associated with rapid remission of depression after electroconvulsive therapy: a latent class growth analysis. Am J Geriatr Psychiatry. 2015;23(3):274-282.
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.
19. Flint AJ, Gagnon N. Effective use of electroconvulsive therapy in late life depression. Can J Psychiatry. 2002;47(8):734-741.
20. Bjolseth TM, Engedal K, Benth JS, et al. Speed of recovery from disorientation may predict the treatment outcome of electroconvulsive therapy (ECT) in elderly patients with major depression. J Affect Disord. 2016;190:178-186.
21. Sackeim HA, Prudic J, Nobler MS, et al. Ultra-brief pulse ECT and the affective and cognitive consequences of ECT. J ECT. 2001;17(1):77.
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Evidence supports using ECT in older patients

Multiple studies have found that ECT is a rapid, safe, and efficacious intervention for treating older persons with depression. Patients age >60 who receive ECT plus pharmacotherapy have lower HAM-D scores than those receiving pharmacotherapy alone.⁵ Overall, the rates of remission for depression range from 50% to 70%; yet geriatric patients who receive only ECT have response rates around 90%.⁶ Older age, presence of psychotic symptoms, and shorter duration of illness can predict a rapidly positive ECT response.⁷

When treated with ECT, older patients, including those age >85, have fewer subsequent episodes of depression compared with those who receive pharmacotherapy alone.¹ Older individuals with physical illness or cognitive impairment respond to and tolerate ECT much like younger patients.⁶ Older patients receiving ECT may experience less cognitive decline than younger ones.⁷ Those in their ninth decade of life with treatment-resistant depression, psychotic features, and post-stroke depression often respond robustly with improvement following ECT.⁸

Remission rates also depend on the technique of administration. Interactions between electrode placement and stimulus parameter dosage affect efficacy and adverse effects.⁹ Right-sided, unilateral ECT induces less cognitive dysfunction compared with bilateral electrode placement,⁹ but bilateral ECT is more clinically effective.¹⁰ However, the efficacy of right-sided ECT is more dose-sensitive, and some data suggest that suboptimal response is due to insufficient stimulus dosages.¹¹ One double-blind randomized controlled trial documented that when using a high-dose stimulus parameter, unilateral ECT is as effective as bilateral ECT.¹² When there is a suboptimal response to unilateral ECT, bilateral ECT might be beneficial.^12,13 For preventing relapse in older patients, increasing the interval between ECT treatments is more effective than stopping ECT abruptly.¹³

Indications of ECT

ECT is indicated for patients with severe depression, mania, and other conditions (Table).¹⁴ The most common indication for ECT in older persons is a history of treatment-resistant depression, with melancholia, psychosis, or suicidal ideations.^1-6,12 There are also age-related and clinical factors to consider with ECT. This treatment provides a safe, rapid remission for patients age >65, even after adjusting for somatic conditions, duration of illness, medication resistance, or case severity.¹⁵ Compared with younger patients, older adults may not tolerate antidepressants as well because of age-related pharmacokinetic alterations, including increased sensitivity to anticholinergic and/or hypotensive effects.¹

Factors that favor ECT include a previous good response to it; patient preference; and an indication for rapid intervention, such as suicidality, catatonia, dehydration, malnutrition, or a suboptimal result from pharmacotherapy.³ Mortality among individuals age >85 who receive ECT reportedly is lower than that among their counterparts who receive alternative treatments.¹⁶ ECT has been administered safely and effectively in patients with comorbid medical illnesses such as stroke, cerebral aneurysm, cardiovascular disease with ischemia or arrhythmia, dementia, and osteoporosis.¹⁷

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

References

Evidence supports using ECT in older patients

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