TREATING POST-STROKE DEPRESSION WITH ECT

Abstract

Introduction Post-stroke depression (PSD) is a common and potentially debilitating sequelae after a stroke, presenting in over 30% of stroke patients. PSD often does not respond to pharmacotherapy and significantly prevents recovery of stroke patients. In addition, depression in geriatric PSD patients may present with more somatic complaints and pain rather than traditional depressive symptoms. Central post-stroke pain syndrome (CPSP), found in 10.6% of patients with ischemic strokes, may present with similar pain and may overlap with symptoms of depression. Multiple studies have demonstrated that ECT is safe and effective in PSD patients, with two studies reporting 88% and 95% efficacy rates. According to the American Psychiatric Association's Task Force on ECT, there are no contraindications to ECT and studies have demonstrated safety in post-stroke patients. After initial ECT treatment, many patients with PSD require maintenance ECT. We present a case of a 62?y/?o female with post-stroke depression with catatonia who responded successfully after 5 ECT sessions but required maintenance ECT to sustain effect. Methods The hospital EMR was used to obtain information regarding this patient and her course of treatment. Results The patient suffered a left MCA infarct in March 2015 which resulted in transcortical motor aphasia. After rehabilitation, she was unable to return to her job as a physical therapist. She experienced worsening depression and suicidal ideation (SI) and required inpatient level psychiatric care, her first psychiatric hospitalization. She was treated with mirtazapine, trazodone, and methylphenidate. Two years later in 2017, she had another depressive episode. During this hospitalization, the patient complained of generalized weakness, diffuse body pain, and inability to move. This resulted in medical hospitalization for malnourishment, complicated by a pulmonary embolus due to immobility. She required PEG tube placement for nourishment, and was continued on mirtazapine, methylphenidate and started on risperidone and venlafaxine. About one year later, in August 2018, she had another depressive episode with catatonia. She refused food and water and refused anticoagulation and other oral medications. Similar to her previous hospitalization, she complained of generalized weakness and chronic pain but denied feelings or symptoms of depression. She was started on unilateral frontal ECT for several sessions and then switched to bitemporal (BT) placement. After about 5 sessions of BT ECT, she began to show improvement and started eating and accepting medications. This patient would have three additional hospitalizations with similar presentations: depression with SI and catatonia-like symptoms with refusal to eat or accept oral medications. She would also complain of pain and generalized weakness as the main reason why should could not move or eat. During these subsequent hospitalizations, ECT was initiated sooner with bitemporal placement which resulted in a more rapid improvement in depression and catatonia. It was determined to start maintenance ECT to prolong the beneficial effects and prevent relapse. Conclusions Post-stroke depression is a common sequalae of cerebrovascular accidents and may not respond adequately to psychopharmacology alone. In the patient presented above, PSD caused life-threatening symptoms: she became suicidal, malnourished, and refused anti-coagulation therapy. After initiation of ECT, symptoms improved, and she became more communicative and less depressed. Due to multiple relapses, maintenance ECT was initiated which helped to prolong duration of time between relapses. This case exemplifies the importance for geriatric providers to recognize weakness and pain as potential symptoms of geriatric depression, specifically PSD and CPSP. As evidenced by our patient, ECT should be more readily considered as symptoms are often refractory to pharmacotherapy alone and ECT maintenance can better prevent relapse of significant depressive symptoms. While additional studies are needed, ECT is safe and should be considered along with pharmacotherapy in PSD patients. This research was funded by: Not applicable