Abstract
Electroconvulsive therapy is used for the management of severe and refractory depression across the age spectrum. Treatment is guided by clinical response. However, there may be differences between the time course of improvement in clinical observations and patients’ self-report of improvements. We report 4 cases of depression in late life that illustrate this issue. We discuss the potential significance of such differences and the need for research.
Keywords: electroconvulsive therapy, treatment response
Dear Editor:
Electroconvulsive therapy (ECT) has been used primarily for acute management of major depression occurring across the life span. Older as well as younger patients with depression can respond well to ECT, and with appropriate patient selection and modern treatment procedures, it is well tolerated.1 Indications include lack of response to, or intolerance of, pharmacotherapy, need for rapid response, and a history of good outcome from ECT.1
Administration of ECT is guided by assessment of individual response. Optimizing benefit involves monitoring of the depressive syndrome and of tolerability. However, there may be differences in time course of observed benefit and change in reported symptoms in some patients. Such differences may need to be taken into account in management.
We report 4 elderly patients who presented with severe depressive syndromes. All had failed medication trials, and had not previously received ECT. They did not have comorbid dementia, personality disorder, or substance abuse. They were in stable physical health and were not taking concomitant benzodiazepines or anticonvulsants. In all cases, treatment was initiated with right unilateral electrode placement at 6 times seizure threshold. They tolerated the ECTwell physically and cognitively.
Case 1
A 70-year-old man presented with major depressive disorder. He reported passive suicidal thoughts, social isolation, loss of interest, lack of motivation, decreased appetite, and insomnia. After 11 ECT, he was observed to have 7 hours of sleep at night without interruption, read books, participate in group therapy, and finish 90% of his meals. However, he continued to report loss of interest and lack of motivation. After the 16th treatment, he started to report some benefit to mood, and this increased through 2 more treatments.
Case 2
A 65-year-old woman was admitted with major depressive disorder. She was isolating herself, neglecting her personal hygiene, and not eating. She suffered from multiple somatic delusions regarding her cardiovascular and gastrointestinal systems. After 8 ECT, she demonstrated improvement in appetite, social interactions, and delusional thinking. However, she continued to report low mood and loss of interest. She reported significant mood improvement during 7 additional treatments.
Case 3
A 68-year-old woman was admitted with diagnosis of major depressive disorder. She presented with loss of interest, crying spells, poor personal hygiene, poor appetite, and suicidal thoughts. After 5 ECT, she was socially interactive and participated in group therapy. She was able to finish 70% of her meals and her personal hygiene improved. Her suicidal thoughts remitted after the seventh ECT. However, she continued reporting depressed mood, which improved during 6 additional treatments.
Case 4
A 63-year-old man with diagnosis of bipolar disorder type I was admitted for worsening nonpsychotic depressive episode. He presented with social isolation, poor self-care, loss of interest, interrupted sleep, and decreased appetite. After 4 ECT, he was socializing with other patients and participating in therapeutic activities, was able to sleep for 7 hours at night, to finish 75% of his meals, and to attend to personal hygiene. Nevertheless, he continued reporting sadness and hopelessness, which improved during 5 additional treatments.
Discussion
These patients demonstrated early improvement of observed features including affect, appetite, sleep, social interaction, participation in groups, and personal hygiene. However, there was a limited initial change in subjective report, that is, in mood, interest, energy, and concentration. Improvement in these dimensions was reported later in treatment. The total number of treatments ranged from 9 to 18.
There is limited ECT literature pertaining to such differences. Zealley and Aitken2 reported that in a 52-year-old bipolar patient receiving ECT for depression, self-rated mood improved more rapidly than nursing assessment, which contrasts with our experience in these cases. Hallam et al3 reported on subjective and objective assessments before and after ECT in 787 mixed-age patients with bipolar and unipolar depression; although clinician ratings improved overall, change in self-report measures depended on the polarity of the mood disorder. Other research characterizing mixed-age depressed patients has indicated that age and severity of symptoms may influence the direction of discrepancies between cross-sectional self-report and observer assessment.4
Our cases raise the question whether there are patient characteristics associated with different rather than congruent time courses of observed and subjective benefit from ECT. Relevant patient characteristics could include age or age-associated factors, diagnosis, symptoms and severity, and illness course.
Initial dissociation of observed and subjective features occurring in some patients may have potential significance for management. Serial assessment guides decisions regarding ECT administration.
In cases 1 and 2, electrode placement was changed to bilateral during the course, whereas cases 3 and 4 had RUL placement throughout. Both placements can be effective and the advantage of switching placements is not clear.5 Nevertheless, treatment-related influences on patterns of observed improvement versus self-report can be studied.
In summary, these cases illustrate differences in time course between observed benefit and patient symptom report during acute ECT for depression. Our experience suggests that research comparing systematic assessments of these domains across treatment course would be worthwhile.
Acknowledgments
Supported by National Institutes of Health Grant K02 MH067028 (Dr Young).
Footnotes
The authors have no conflicts of interest or financial disclosures to report.
References
- 1.O’Connor MF, Knapp R, Husain M, et al. The influence of age on the response of major depression to electroconvulsive therapy. Am J Geriatr Psychiatry. 2001;9:382–390. [PubMed] [Google Scholar]
- 2.Zealley AK, Aitken RC. Measurement of mood. Proc R Soc Med. 1969;62:993–996. doi: 10.1177/003591576906201006. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Hallam KT, Smith DI, Berk M. Differences between subjective and objective assessments of the utility of electroconvulsive therapy in patients with bipolar and unipolar depression. J Affect Disord. 2009;112:212–218. doi: 10.1016/j.jad.2008.03.024. [DOI] [PubMed] [Google Scholar]
- 4.Prusoff BA, Klerman GL, Paykel ES. Pitfalls in the self-report assessment of depression. Can Psychiatr Assoc J. 1972;17(suppl 2):SS101. doi: 10.1177/07067437720176s218. [DOI] [PubMed] [Google Scholar]
- 5.Tew JD, Jr, Mulsant BH, Haskett RF, et al. A randomized comparison of high-charge right unilateral electroconvulsive therapy and bilateral electroconvulsive therapy in older depressed patients who failed to respond to 5 to 8 moderate-charge right unilateral treatments. J Clin Psychiatry. 2002;63:1102–1105. doi: 10.4088/jcp.v63n1203. [DOI] [PubMed] [Google Scholar]