Brain Stimulation Therapies
WHEN an older patient fails to respond to other interventions, you should consider treatments that electrically stimulate the brain, either through the direct application of electricity or by the generation of electrical currents with magnets. The most commonly used brain stimulation intervention, electroconvulsive therapy (ECT), can have startling benefits for older patients. ECT is underutilized in community settings, however, both because of stigma around the treatment and because it requires additional resources, including specialized training and equipment; thorough and frequent evaluations; and transportation to and from the procedure. Although these barriers prevent ECT and related treatments from being offered outside of mental health specialty settings at present, these treatments are so essential to geriatric psychiatry that every practitioner needs to be aware of their benefits and risks. The field of brain stimulation interventions is rapidly growing in importance as newer and more convenient techniques are being created.
Siegfried is an 89-year-old man who is brought to your clinic by his two grandchildren. They are concerned because over the past few months, Siegfried has had significant decreased oral intake and is lying in bed all day. He has lost interest in his family and his hobbies. He appears dysphoric and speaks slowly. Siegfried explains that he is eating less because he has abdominal pain that he believes is due to stomach cancer, although his medical workup for abdominal pain has been negative. You take his blood pressure and realize that he is orthostatic. You admit him to the medical unit and request psychiatry consultation for ECT to treat his probable major depressive disorder with psychotic features.
ECT is one of the oldest and most effective treatments in psychiatry. It is used mainly to treat major depressive disorder, but other indications include mania and Parkinson’s disease (Cumper et al. 2014; Medda et al. 2014). ECT works by inducing a generalized tonic-clonic seizure via electrical stimulation delivered through electrodes attached to a patient’s scalp. The placement of these electrodes requires a balancing act between maximizing the therapeutic effect and minimizing any adverse effect on cognition. Shorter pulse widths of electrical current are generally used because they are less likely to cause cognitive damage without significantly affecting therapeutic efficacy. One of the most common approaches in ECT is the right unilateral ultrabrief pulse, which maximizes therapeutic efficacy while minimizing adverse cognitive effects (Mankad et al. 2010). No matter what type of ECT is administered, patients undergo anesthesia and are given muscle relaxants to avoid being injured secondary to the induced convulsions (Adachi et al. 2006).
Although ECT can be a quick intervention to help ease suffering from treatment-refractory depression or major depressive disorder with psychosis in older adults, many patients do not pursue this treatment because ECT practitioners are scarce, especially in rural and underserved areas, and finding a caregiver to provide regular transportation to and from the treatment, as often as thrice weekly, may be difficult. Another factor is the negative perception of ECT based on mass media depictions of “shock therapy” when the procedure was still being developed. If primary care or mental health practitioners refer patients for ECT evaluations, they should explain to their patients that today’s ECT is a safe, highly standardized procedure that occurs under anesthesia. Practitioners should also inform patients that ECT is highly efficacious, particularly for patients who have not responded to psychotropic medications and psychotherapy (Lisanby 2007). Older adults may particularly benefit from ECT because they are more likely than younger adults to have treatment-refractory depression (Riva-Posse et al. 2013).
ECT, however, does have some significant adverse effects. The most serious are cardiac arrhythmias and other cardiovascular complications. Cardiac clearance for older adults or patients with preexisting cardiac disease is important in order to prevent these complications. It is usually recommended that patients age 50 and older undergo a baseline electrocardiogram (Sundsted et al. 2014). With proper consultation from cardiology and management by anesthesiology, most patients with cardiac disease are still able to receive ECT. The rate of all cardiac complications is 0.9% (Sundsted et al. 2014). Most of these cardiac complications are due to arrhythmias.
Cognitive impairment after ECT is a well-publicized side effect, but large-scale prevalence studies have not been done (Verwijk et al. 2012). It is estimated that cognitive impairment may affect up to 50% of patients, but amnesia is a less frequent problem than it used to be because many practitioners have now modified their procedures to use brief pulse unilateral or ultrabrief pulse ECT to minimize cognitive side effects instead of starting with bilateral ECT (Verwijk et al. 2012). The types of cognitive impairment associated with ECT are anterograde and retrograde amnesia. Generally, anterograde amnesia resolves within a month, whereas retrograde amnesia takes longer to resolve and may not resolve fully, especially in patients who receive ongoing ECT treatments (Lisanby 2007; McClintock et al. 2014; Semkovska and McLoughlin 2010). Some patients’ depressive symptoms may not respond to unilateral ECT and may require bilateral ECT; these patients are at much higher risk for cognitive impairment. Another side effect of ECT is postictal delirium, which occurs in about 12% of patients (Fink 1993). Episodes of delirium usually happen with the initial treatments and self-resolve within an hour.
Siegfried is placed on intravenous fluids and consents to have 10 sessions of ECT to determine whether he will respond. By the fourth session, Siegfried is drinking enough that he no longer requires intravenous fluids. By the tenth session, his delusion that he has stomach cancer and cannot eat is significantly less intense, and his solid intake improves significantly. Siegfried is medically stable enough that he is transferred to inpatient psychiatry to continue his course of ECT, which is given three times a week.
After Siegfried has received ECT for 1 month, he and his grandchildren agree to the recommendation that he have maintenance ECT. After several more months, the maintenance ECT is tapered, and Siegfried maintains fairly good control of his depressive symptoms.