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Vol 16, No 4
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<p class="frontmatter-fieldnotes disclaimernew" style="margin-bottom:15px;">This work may not be copied, distributed, displayed, published, reproduced, transmitted, modified, posted, sold, licensed, or used for commercial purposes. By downloading this file, you are agreeing to the publisher’s <a href="/pages/termsofuse.aspx" target="_blank">Terms & Conditions</a>.</p> <div id="x14l01640">
<div class="story">
<p class="ltrs-br-ltr-br-title"><span class="bold">Treatment-Resistant Depression Requiring Electroconvulsive Therapy Following Stem Cell Transplantation</span></p>
<p class="ltrs-br-ltr-br-body-text"><span class="semibold">To the Editor:</span> In an effort to improve hematologic cancer outcomes, there is growing interest in combining psychiatric and oncologic treatment. We present the first report of a patient with depression resistant to multiple antidepressants who underwent serial electroconvulsive therapy (ECT) sessions following allogeneic stem cell transplantation (SCT). </p>
<p class="ltrs-br-ltr-br-body-text">&nbsp;</p>
<p class="ltrs-br-ltr-br-body-text"><span class="semibold-ital">Case report.</span> Ms A is a 38-year-old woman with acute T-cell lymphoblastic leukemia. Her past medical history is significant for hypothyroidism and depression with past trials of sertraline, bupropion, and escitalopram. Due to adverse effects, she has not taken antidepressants in 10 years.</p>
<p class="ltrs-br-ltr-br-body-text">Following diagnosis of leukemia, Ms A began chemotherapy and was started on mirtazapine, trazodone, and clonazepam treatment for mood symptoms. Her medical condition failed to improve and SCT was recommended. Additionally, psychiatry was consulted to evaluate for depression characterized by hypersomnia and anorexia without feelings of hopelessness and suicidal ideation. She screened negative for major depression and bipolar disorder. A psychiatric diagnosis was not made at this time.</p>
<p class="ltrs-br-ltr-br-body-text">Following SCT, Ms A’s symptoms worsened, so we prescribed venlafaxine and stopped mirtazapine therapy. Moreover, clostridium<span class="italic"> </span>difficile colitis with hypothyroidism secondary to levothyroxine malabsorption contributed to her depression. Levothyroxine was given intravenously, and methylphenidate was started but discontinued due to anorexia.</p>
<p class="ltrs-br-ltr-br-body-text">Ms A’s SCT recovery was complicated by worsening mood, decreased nutritional intake, renal failure, respiratory failure, pericardial effusion, and physical deconditioning. These factors made rehabilitation difficult due to poor motivation and inability to maintain hygiene and complete tasks of daily living.</p>
<p class="ltrs-br-ltr-br-body-text">We increased Ms A’s venlafaxine and trazodone dosages. Despite these changes, due to her profound depression and refusal to eat, she was transferred to our inpatient psychiatric unit. We scheduled triweekly ECT for a total of 12 initial treatments. Ms A’s apathy worsened to the point of soiling herself and not informing her nurses, so we started her on olanzapine but stopped due to adverse effects. Concurrently, she continued ECT with appreciable improvements after 6 treatments.</p>
<p class="ltrs-br-ltr-br-body-text">After multiple weeks of ECT, Ms A’s Beck Depression Inventory score went from 29 to 12.<span class="htm-cite"><a href="#ref1">1</a></span> Her mood and function markedly improved. Currently, she has no evidence of cancer relapse or graft rejection and returns to our hospital system for follow-up and bimonthly ECT maintenance.</p>
<p class="ltrs-br-ltr-br-body-text">&nbsp;</p>
<p class="ltrs-br-ltr-br-body-text">There is growing interest in the relation between cancer and comorbid psychosocial distress, as well as psychiatric interventions optimizing clinical outcomes.<span class="htm-cite"><a href="#ref2">2</a>,<a href="#ref3">3</a></span> True depression is reported in 4%–49% of cancer patients depending on the severity of the disease.<span class="htm-cite"><a href="#ref4">4</a>,<a href="#ref5">5</a></span></p>
<p class="ltrs-br-ltr-br-body-text">Levels of depression and social support prior to SCT predict the extent of physical and emotional recovery.<span class="htm-cite"><a href="#ref6">6</a></span> This is the first report of successful ECT following SCT, suggesting that ECT is safe and effective in patients with depression undergoing SCT.</p>
<p class="ltrs-br-ltr-br-body-text">Early neuropsychiatric intervention in cancer patients leads to better patient outcomes and long-term reductions in psychosocial distress, but surveys suggest that physicians rarely manage depression until late in the disease course.<span class="htm-cite"><a href="#ref7">7</a></span> One reason may be a desire to minimize cost. Another possibility is the lack of a standardized approach to cancer patients with mood disorders. These reasons may explain why ECT is so underutilized. Given the rapid response demonstrated with ECT, early treatment may be more cost effective by preventing prolonged hospitalization. Further cost analysis is warranted to compare ECT versus less invasive treatment and longer hospital stay.<span class="htm-cite"><a href="#ref8">8–13</a></span></p>
<p class="ltrs-br-ltr-br-body-text">For our patient, ECT correlated with improved Beck Depression Inventory scores and daily functioning consistent with the literature.<span class="htm-cite"><a href="#ref14">14</a></span> Her gradual worsening of depression and medical complications may have delayed ECT. Earlier treatment may have decreased hospitalization time and improved overall recovery.</p>
<p class="ltrs-br-ltr-br-body-text">Further investigation into the efficacy of ECT in patients with multiple comorbidities following SCT is warranted. Earlier improvement of depressive symptoms may prevent medical complications and shorten recovery time. Future cost analysis would be helpful to compare early ECT with minimally invasive treatment.</p>
<p class="ltrs-br-ltr-br-references-head"><span class="smallcaps">References</span></p>
<p class="references-references-text-1-9"><a name="ref1"></a>1. Beck AT, Ward CH, Mendelson M, et al. An inventory for measuring depression. <span class="italic">Arch Gen Psychiatry</span>. 1961;4(6):561–571. <span class="pubmed-crossref"><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=13688369&dopt=Abstract">PubMed</a> <a href="http://dx.doi.org/10.1001/archpsyc.1961.01710120031004">doi:10.1001/archpsyc.1961.01710120031004</a></span></p>
<p class="references-references-text-1-9"><a name="ref2"></a>2. National Comprehensive Cancer Network. NCCN practice guidelines for the management of psychosocial distress. <span class="italic">Oncology (Williston Park)</span>. 1999;13(5A):113–147. <span class="pubmed-crossref"><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10370925&dopt=Abstract">PubMed</a></span></p>
<p class="references-references-text-1-9"><a name="ref3"></a>3. Galway K, Black A, Cantwell M, et al. Psychosocial interventions to improve quality of life and emotional wellbeing for recently diagnosed cancer patients. <span class="italic">Cochrane Database Syst Rev</span>. 2012;11:CD007064. <span class="pubmed-crossref"><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=23152241&dopt=Abstract">PubMed</a> <a href="http://dx.doi.org/10.1002/14651858.cd007064.pub2">doi:10.1002/14651858.CD007064.pub2</a></span></p>
<p class="references-references-text-1-9"><a name="ref4"></a>4. Pirl WF. Evidence report on the occurrence, assessment, and treatment of depression in cancer patients. <span class="italic">J&nbsp;Natl Cancer Inst Monogr</span>. 2004;32(32):32–39. <span class="pubmed-crossref"><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=15263039&dopt=Abstract">PubMed</a> <a href="http://dx.doi.org/10.1093/jncimonographs/lgh026">doi:10.1093/jncimonographs/lgh026</a></span></p>
<p class="references-references-text-1-9"><a name="ref5"></a>5. Walker J, Hansen C, Martin P, et al. Prevalence of depression in adults with cancer: a systematic review. <span class="italic">Ann Oncol</span>. 2013;24(4):895–900. <span class="pubmed-crossref"><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=23175625&dopt=Abstract">PubMed</a></span></p>
<p class="references-references-text-1-9"><a name="ref6"></a>6. Syrjala KL, Langer SL, Abrams JR, et al. Recovery and long-term function after hematopoietic cell transplantation for leukemia or lymphoma. <span class="italic">JAMA</span>. 2004;291(19):2335–2343. <span class="pubmed-crossref"><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=15150205&dopt=Abstract">PubMed</a> <a href="http://dx.doi.org/10.1001/jama.291.19.2335">doi:10.1001/jama.291.19.2335</a></span></p>
<p class="references-references-text-1-9"><a name="ref7"></a>7. Jacobsen PB, Ransom S. Implementation of NCCN distress management guidelines by member institutions. <span class="italic">J&nbsp;Natl Compr Canc Netw</span>. 2007;5(1):99–103. <span class="pubmed-crossref"><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=17239329&dopt=Abstract">PubMed</a></span></p>
<p class="references-references-text-1-9"><a name="ref8"></a>8. Husain MM, Rush AJ, Fink M, et al. Speed of response and remission in major depressive disorder with acute electroconvulsive therapy (ECT): a Consortium for Research in ECT (CORE) report. <span class="italic">J&nbsp;Clin Psychiatry</span>. 2004;65(4):485–491. <span class="pubmed-crossref"><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=15119910&dopt=Abstract">PubMed</a> <a href="http://dx.doi.org/10.4088/JCP.v65n0406">doi:10.4088/JCP.v65n0406</a></span></p>
<p class="references-references-text-1-9"><a name="ref9"></a>9. Prieto JM, Blanch J, Atala J, et al. Psychiatric morbidity and impact on hospital length of stay among hematologic cancer patients receiving stem-cell transplantation. <span class="italic">J&nbsp;Clin Oncol</span>. 2002;20(7):1907–1917. <span class="pubmed-crossref"><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11919251&dopt=Abstract">PubMed</a> <a href="http://dx.doi.org/10.1200/JCO.2002.07.101">doi:10.1200/JCO.2002.07.101</a></span></p>
<p class="references-references-text-10-99"><a name="ref10"></a>10. Kellner CH, Knapp RG, Petrides G, et al. Continuation electroconvulsive therapy vs pharmacotherapy for relapse prevention in major depression: a multisite study from the Consortium for Research in Electroconvulsive Therapy (CORE). <span class="italic">Arch Gen Psychiatry</span>. 2006;63(12):1337–1344. <span class="pubmed-crossref"><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=17146008&dopt=Abstract">PubMed</a> <a href="http://dx.doi.org/10.1001/archpsyc.63.12.1337">doi:10.1001/archpsyc.63.12.1337</a></span></p>
<p class="references-references-text-10-99"><a name="ref11"></a>11. Kalapatapu R. Electroconvulsive therapy. <span class="italic">Medscape.</span> <a href="http://emedicine.medscape.com/article/1525957-overview#a01">http://emedicine.medscape.com/article/1525957-overview#a01</a>. Updated June 26, 2012. Accessed March 26, 2014.</p>
<p class="references-references-text-10-99"><a name="ref12"></a>12. Kellner CH, Greenberg RM, Murrough JW, et al. ECT in treatment-resistant depression. <span class="italic">Am J Psychiatry</span>. 2012;169(12):1238–1244. <span class="pubmed-crossref"><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=23212054&dopt=Abstract">PubMed</a> <a href="http://dx.doi.org/10.1176/appi.ajp.2012.12050648">doi:10.1176/appi.ajp.2012.12050648</a></span></p>
<p class="references-references-text-10-99"><a name="ref13"></a>13. Gelenberg A, Freeman M, Markowitz J, et al. <span class="italic">Practice Guideline for the Treatment of Patients With Major Depressive Disorder</span>. 3rd ed. Washington, DC: American Psychiatric Association; 2010:44.</p>
<p class="references-references-text-10-99"><a name="ref14"></a>14. The UK ECT Review Group. Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis. <span class="italic">Lancet</span>. 2003;361:799–808.</p>
<p class="ltrs-br-ltr-br-author"><span class="bold">Dana Raml, BS</span></p>
<p class="ltrs-br-ltr-br-author"><a href="mailto:dana.bell@unmc.edu">dana.bell@unmc.edu</a></p>
<p class="ltrs-br-ltr-br-author"><span class="bold">Matthew Kelly, BS</span></p>
<p class="ltrs-br-ltr-br-author"><span class="bold">Ashish Sharma, MD</span></p>
<p class="ltrs-br-ltr-br-endmatter-fieldnotes"><span class="semibold-ital">Author affiliations:</span> College of Medicine, University of Nebraska, Omaha.</p>
<p class="ltrs-br-ltr-br-endmatter-fieldnotes"><span class="semibold-ital">Potential conflicts of interest: </span>None reported.</p>
<p class="ltrs-br-ltr-br-endmatter-fieldnotes"><span class="semibold-ital">Funding/support:</span> None reported.</p>
<p class="ltrs-br-ltr-br-endmatter-fieldnotes"><span class="semibold-ital">Published online:</span> August 28, 2014.</p>
<p class="ltrs-br-ltr-br-endmatter-fieldnotes"><span class="italic">Prim Care Companion CNS Disord 2014;16(4):</span><span class="doi">doi:10:4088/PCC.14l01640</span></p>
<p class="ltrs-br-ltr-br-endmatter-fieldnotes"><span class="italic">© Copyright 2014 Physicians Postgraduate Press, Inc.</span></p>
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