“It Ain't Over til ….”: ECT, Depression, Competency, and Ethical Dilemmas

Abstract

To the Editor:—In Dr. Lee's recent discussion1 about how to proceed when an aged patient with major depression and life-threatening illness refuses treatment, she attempts to provide further guidance in “addressing the complexities of caring for such depressed frail older patients.” Dr. Lee is to be commended for her practicality and clear thinking. She discusses the recognition of depression in such patients and recommends seeking psychiatric consultation regarding its treatment, especially when questions of associated non-competency are present. While the purpose of our letter is not to deal specifically with the reported case, it does raise several issues regarding the treatment of depressed elderly and many other medically-ill depressives as well. Georgotos2 and our own work3 have shown that depression in the elderly often takes as much as 12 weeks of therapeutic dosing to achieve a response; moreover, this is in the non-frail elderly. Dr. Lee's patient received only a 2-day trial of desipramine and then a 5-week trial of fluoxetine before refusing further medications. Unfortunately, it appears that her patient may not have had a fully adequate therapeutic trial of thymoleptic medication. Complicating the clinical picture in this case is a recent report by Teicher4 which, though needing confirmation, has suggested that fluoxetine may, in some patients, exacerbate suicidal ideation. In view of the necessity for feeding tube placement and the patient's refusal of medication, it seems to our group that, as a part of Dr. Lee's otherwise practical and sequential approach, more serious consideration should have been given to a trial of electroconvulsive therapy. In her article, Dr. Lee refers to the benefits of electroconvulsive therapy for the elderly, but she also speaks about the increased morbidity in patients over 75 years of age. We have recently reported on the comparative safety of this intervention in three medically frail 90+-year-old patients when judiciously applied and carefully monitored. Our experience is not inconsistent with numerous reports of others who have used ECT extensively in such patients. Dr. Lee's patient, though suffering from angina, heart failure, and renal failure, could have been considered for this therapy. It seems that the decision by both his doctors and family to respect the patients “consistent” wishes over time, with regard to having no further treatment, was based on the arguably inaccurate belief that he had received a fully adequate trial of thymolepsis. Given the 50%-80% positive response rate to ECT of depressed, medication-non-responsive patients and the relative safety, even in medically-frail patients, of this treatment, a “fully adequate trial of thymolepsis'’ should include a course of ECT (or at least serious consideration thereof) before abandoning treatment. The most important principle in the treatment of geriatric depression is to be non-reckless but aggressive, thorough, and systematic. In patients who accept medication treatment we prefer two different trials of thymoleptic (anti-depressant) agents with adequate dosing for adequate periods of time. In patients who fail to respond, we then offer augmentation treatment with antidepressant or other agents (lithium, thyroid) or a course of ECT as a final alternative. For patients who refuse treatment with medication and indeed are refusing all PO intake, we encourage the family to obtain guardianship and secure court-ordered approval for ECT after explaining to them its benefits and hazards in the treatment of depression. Of course, medical stabilization must be achieved prior to starting ECT. Despite all the above, we realize that there will still be a significant number of treatment-refractory patients. The physician and family can then take comfort in the fact that the most effective treatments for depression including ECT—the “gold standard” antidepressant treatment modality—have been tried and found ineffective or considered and deemed too risky. In the case above, it would have perhaps been preferable for the health care team and family to have made their decision in favor of “comfort measures only” on such a basis.