The following article is a part of conference coverage from the American Psychiatric Nurses Association (APNA) 34th Annual Conference, held online from September 30 to October 4, 2020. The team at the Clinical Advisor will be reporting on the latest news and research conducted by leading nurses in psychiatry. Check back for more from APNA 2020.

 

Electroconvulsive therapy (ECT) successfully reduced symptoms of psychiatric illnesses in 4 patients with varying mental health diagnoses, according to a poster presented at the American Psychiatric Nurses Association 34th Annual Conference, held online from September 30th to October 4th, 2020.

The 4 case studies include “real people, real results” with different applications of ECT, a collaborative effort of nurses working at ECT centers at the University of Michigan in Ann Arbor, and McLean Hospital in Belmont, Massachusetts.

Case 1: Treatment-Resistant Depression

A 54-year-old White man presents with daily panic attacks, anhedonia, lack of motivation, indecisiveness, confusion, and poor concentration due to worsening depression. The patient is not actively suicidal and has previous diagnoses of bipolar disorder, generalized anxiety disorder, mild obsessive compulsive disorder, and attention deficit hyperactivity disorder.


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The patient is currently taking clonazepam, desvenlafaxine, and vilazodone; antipsychotics, mood stabilizers, and esketamine have failed to improve the patient’s symptoms.

The patient was admitted to an inpatient unit as a safety measure due to elevated risk of self-harm and to optimize his medications. He was titrated off all current medications and started on a tricyclic antidepressant. The patient was then discharged, but was admitted 5 days later due to depressive symptoms and feelings of hopelessness.

Clinicians decided to treat this patient with ECT. “It is highly effective for depression and the rates of remission range from 50 to 60% in a matter of weeks,” noted the authors, as compared with pharmacotherapy, which has a remission rate ranging between 10 and 40%.

The patient underwent unilateral ECT and remained in the hospital for 6 days before being discharged to continue outpatient treatment. In total, the patient received 18 acute course treatments; the first 6 were unilateral, but clinicians switched to bilateral ECT due to the severity and persistence of the patient’s symptoms. The treatment was then tapered to once weekly for maintenance.

The patient reported significant improvements in his mood and anxiety levels after receiving ECT. The patient’s panic attacks ceased entirely, and he became future-oriented and better at making decisions.

Case 2: Agitated Dementia

A 74-year-old woman presents with major cognitive disorder due to Alzheimer disease. The patient has no prior psychiatric history.

After being admitted to the Older Adult Unit, the patient began experiencing delusions and behavioral disturbances including physical attacks on staff members and other residents. The patient frequently yelled and sought exits and was aggressive during daily care. She also experienced paranoia.

The patient’s medication trials included melatonin at bedtime and lorazepam as needed; during her in-patient stay she was started on mirtazapine, risperidone, and donepezil. The patient was then discharged, but readmitted 2 months later with continued behavioral disturbances. She was given olanzapine, and then quetiapinel.

With the consent of the patient’s husband, who was her durable power of attorney, the patient completed an acute series of 8 ECT treatments and 2 maintenance treatments in the hospital.

The patient responded well to ECT combined with medications; she became less agitated and aggressive, no longer experienced paranoid delusions, and was able to be discharged back to the long-term care facility. The patient continued to receive ECT every other week until she reached end-stage Alzheimer disease and entered hospice care. Her husband expressed gratitude for ECT and how it improved his wife’s quality of life.

Case 3: Catatonia

A 34-year-old Black woman with bipolar I disorder complicated by catatonia was hospitalized after a recent episode began with paranoia and increased anxiety. Her catatonic symptoms included mutism, rarely blinking, difficulty swallowing food, slowed movements, intermittent agitation, and posturing. The patient was started on high-dose lorazepam; she received 30 mg over 48 hours followed by 21 mg per day with some positive effects.

Since ECT has a reported efficacy rate ranging between 80 and100% for resolving catatonia, clinicians chose to pursue ECT for this patient. ECT is effective even in patients for whom a benzodiazepine was not effective. Since the patient was deemed unable to consent, the patient received bilateral ECT for 11 inpatient treatments through a court order, and her catatonic symptoms completely resolved.

The inpatient team decided to start the patient on paliperidone, and implemented a plan to start the patient on lithium when she resumes care with the outpatient team. The patient was eventually discharged from the inpatient unit and was able to continue ECT treatment in an outpatient facility. The patient now receives monthly maintenance treatments; she was able to return to work and rates her mood as an 8 out of 10. She stated all symptoms of catatonia are completely resolved.

Case 4: Agitated Mania

A 70-year-old woman presents to the emergency room with confusion, anxiety, erratic behavior, paranoid delusions, and angry outbursts. She has a history of bipolar disorder with psychosis. Her symptoms include disorganization, nonsensical speech, disrobing, intrusiveness, and poor sleep.

The patient had been treated with lamotrigine, lorazepam, and fluoxetine. She also was prescribed risperidone for her psychotic symptoms, and trazadone to assist with sleep.

In the hospital, the patient received an acute course of 10 bilateral ECT treatments combined with 150 mg lithium per day. This treatment plan completely resolved her irregular mood and manic symptoms.

The patient’s treatments were interrupted when she tested positive for COVID-19, but she was able to resume her treatments on an outpatient basis after her infection resolved. In total, the patient received 15 additional outpatient ECT treatments and has continued her maintenance treatments without experiencing a relapse in manic symptoms, though she does report occasional dips in her mood.

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Reference

Bolton P, Henderson T, Miller D, Cook M, Singley J. Electroconvulsive therapy: real people, real results. Presented at: APNA Annual Conference; September 30-October 4, 2020.  Poster 55.