|Year : 2018 | Volume
| Issue : 2 | Page : 144-146
Nonresponsive responder! –Somatic symptoms presenting as refractory depression with response to electroconvulsive therapy
Suhas Chandran, M Kishor, Shreemit Maheshwari, Supriya Mathur, TS Sathyanarayana Rao
Department of Psychiatry, JSS Medical College and Hospital, JSS University, Mysore, Karnataka, India
|Date of Web Publication||30-Nov-2018|
Department of Psychiatry, JSS Medical College and Hospital, JSS University, Mysore - 570 004, Karnataka
Source of Support: None, Conflict of Interest: None
Depression is a condition that can present with varied signs and symptoms. Physical pain, although not stated as a symptom of depression according to the official psychiatric classification systems of the Diagnostic and Statistical Manual of Mental Disorders and International Classification of Diseases, 10th revision, is also frequently reported by patients with depression. Physical symptoms, common in major depression may lead to chronic pain, often complicating treatment and is generally accompanied by a significant level of dysfunction. A multi-pronged approach often becomes necessary in such patients. They are amenable to numerous strategies including cognitive behavioral therapy (CBT), pharmacotherapy and in some resistant cases electroconvulsive therapy (ECT) also becomes an effective treatment approach. The use of ECT becomes even more pertinent in patients who fail to achieve remission despite being treated with CBT and various pharmacological regimens. We hereby report a case of a 61-year-old man with depression, presenting with pain abdomen as a part of recurrent depressive disorder who eventually responded to the use of ECT as a therapeutic modality. The potential role of the dose of the anesthetic agent influencing the efficacy of the ECT has also been highlighted.
Keywords: Depression, dose of anesthetic agent, electroconvulsive therapy, refractory abdominal pain
|How to cite this article:|
Chandran S, Kishor M, Maheshwari S, Mathur S, Sathyanarayana Rao T S. Nonresponsive responder! –Somatic symptoms presenting as refractory depression with response to electroconvulsive therapy. Ann Indian Psychiatry 2018;2:144-6
|How to cite this URL:|
Chandran S, Kishor M, Maheshwari S, Mathur S, Sathyanarayana Rao T S. Nonresponsive responder! –Somatic symptoms presenting as refractory depression with response to electroconvulsive therapy. Ann Indian Psychiatry [serial online] 2018 [cited 2019 Jun 19];2:144-6. Available from: http://www.anip.co.in/text.asp?2018/2/2/144/246527
| Introduction|| |
There is a historical custom in phenomenological psychopathology that emphasizes somatic symptoms as core features of depressive states. The second version of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM-IV TR) incorporated new criteria referring to ”excessive worry over physical health and complaints of pain (e.g., headaches or joint, abdominal, or other pains).” In International Classification of Diseases, 10th revision (ICD-10), disturbances of sleep and appetite, loss of libido, and weight loss are the only somatic symptoms considered to be of diagnostic significance for major depression. Beyond this short list of predominantly vegetative symptoms, no painful physical symptoms are mentioned in either the earlier version of DSM-IV or ICD-10. This somatic form of presentation, however, significantly contributes to low rates of recognition in primary care. A diagnostic challenge may be seen in the differentiation of a depression with prevailing somatic symptoms from medical conditions. A few patients with depression may only complain of physical symptoms and may not complain of affective symptoms during their illness. Subsequently, these patients seek care to find an organic disease they fear but do not have. In 1999, Simon et al. analyzed 1146 patients from 14 countries and concluded that 69% of the patients reported only of somatic complaints. Doctors in such situations may then test for and even treat a nonexistent organic disease when these physical symptoms associated with depression may be interpreted as symptoms of a somatic illness. Diagnosis is therefore not merely the exclusion of serious physical problems but also the combined consideration of such medically unexplained symptoms and classic psychiatric disorders. Depression as a diagnosis is more likely if there is a past or current history of depression or anxiety. When painful physical conditions, enmesh with the already debilitating psychiatric and behavioral symptoms of depression, the course of the illness may become more severe, implying a higher risk of early relapse, suicide, or mortality due to other natural causes, the functional status may be impaired, increased caregiver burden all of which may significantly lower the overall health-related quality of life. The economic burden also increases considerably with a lack of satisfaction of patients leading to significantly higher health-care utilization and high associated costs. We hereby report a case of pain abdomen that was part of an atypical presentation of depression that responded to the use of electroconvulsive therapy (ECT) as a therapeutic modality.
| Case Report|| |
A 61-year-old man presented with episodic illness for the past 20 years with each episode characterized by tiredness, sadness of mood, multiple body aches, loss of interest, decreased sleep which varied from 2 to 6 weeks. The patient had a history of suicidal attempt of low lethality 3 years back. There was no history of mania, psychosis, substance use in the illness duration or any family history of psychiatric illness. He had failed to respond optimally to multiple classes of antidepressants, mood stabilizers, and antipsychotics. He did not respond to a trial of cognitive behavioral therapy (CBT) either.
However, he responded well to Modified ECT with improvement in both the somatic and affective symptoms and was well maintained for 8–12 months before he had another episode. Two months back, the patient presented with abdominal pain, which was generalized, dull aching, continuous, causing functional limitation, and non-responsive to a trial of antispasmodic as well as anti-reflux medications. The patient sought opinions of a physician, surgeon and a gastroenterologist. Clinical examinations as well as investigations including (Complete Hemogram, Liver function tests, Renal Function Tests, Serum Lipase and Amylase levels) and Imaging tests (USG Abdomen, Upper GI endoscopy) revealed no abnormalities. Although abdominal pain was the most prominent symptom, it was concurrent with the similar symptomatology of previous episodes.
As patient was not improving he took a second opinion and was considered for a course of modified ECTs despite which there was no remission in his abdominal pain. This nonresponse to ECT was the first of its instance in the entire 20-year duration of illness. The patient had received 6 ECTs in that hospital [Table 1]. However, when he failed to respond even after 4 weeks, he reverted back to us. A detailed re-evaluation revealed use of a higher anesthetic dose in proportion to his body weight and this coupled with a lack of electroencephalography monitoring for seizures could possibly have led to non-remission in symptomatology, unlike the previous episodes. The patient weighed 68 kg with a BMI of 23. The anesthetic agent used was propofol at a dose of 2 mg/kg which falls on the upper end of the recommended dose of propofol for ECT at 0.75–2.5 mg/kg. Succinylcholine was the muscle relaxant used, and its dosage was at par with the recommended dosage of 0.5–1 mg/kg. On admission in our setting, the patient was given 5 ECTs over the course of 10 days. Care was taken to ensure use of an appropriate dose of propofol [Table 2] and the patient showed progressive improvement with each ECTs and reduction in pain. The patient is currently maintaining well at the end of 3 weeks with no abdominal pain. He was also advised to start yoga as an additional measure overall to reduce relapse rate.
| Discussion|| |
Depression is the most common psychiatric condition that can present with varied signs and symptoms. Depression is a risk factor for the development of pain. These individuals report greater pain intensity. In some individuals, depression may only manifest as pain, and in some individuals the core affective symptoms disappear early in treatment, but the physical symptoms may linger on. In cases of recurrent depressive disorders, pain might possibly be the only presenting symptom in subsequent episodes. Abdominal pain in this case which presented for the first time in 20 years was a challenge and qualified for medically unexplained symptom. Medical care of such patients should include management of three interrelated elements: diagnosis, specific treatment strategies, and long-term maintenance of improvement. The narrow focus on the somatic aspects of a complex problem may reinforce patient concerns about having a physical disease, enhance caregiver burden and contribute to the development of chronic disablement. Hence, a multi-pronged approach becomes necessary. These individuals are amenable to numerous strategies including CBT and pharmacotherapy. In this case, abdominal pain which was part of depression responded to the use of ECT and was an effective treatment modality.
Clinicians must however be aware of the anesthetic factors that may influence the efficacy of ECT and use of higher dosages of the anesthetic agent can lower the seizure duration and reduce efficacy of the modality, which is what could have probably happened in this case at the first ECT course where the patient failed to respond. Anesthesia not only enables the ECT procedure but can also have a significant influence on its clinical efficacy and tolerability through its influence on electrophysiological parameters and seizure variables. The level of anesthesia should not be so deep as to overly suppress the seizure activity which is the goal of the treatment. Methohexital is an ultrashort-acting barbiturate and is considered the drug of choice in ECT anesthesia. A review comparing methohexital with propofol noted that a propofol dose of 0.75 mg/kg was associated with seizure durations similar to those of methohexital. The seizure duration of propofol is however significantly shorter than methohexital when the dose is increased up to 1.5 mg/kg or above. The dose of anesthetic agent is initially titrated to patient weight but modified thereafter as necessary depending on previous response to ECT and any changing seizure thresholds. The relationship between the ECT seizure length and efficacy still remains unclear. The efficacy of ECT depends not only on factors such as the correct choice of anesthetic drugs for the individual patient, which have to be chosen with respect to the concomitant medication and pre-existing diseases but it could also potentially depend on the dose of this anesthetic agent used. This possible association however needs further research and could be of key therapeutic value.
Previous studies have reported the potential for ECT to create long-term structural changes in the limbic system and the prefrontal cortex including improved structural brain plasticity and ECT-related hippocampal volume increases. ECT may also affect regional cerebral blood flows or cerebral metabolic rates. Cerebral blood flow during ECT is found to be increased particularly in the basal ganglia, brain-stem, diencephalon, amygdala, vermis and the frontal, temporal, and parietal cortices compared with that before ECT and the flow is increased in the thalamus post-ECT which is postulated to be contributory to the therapeutic effects of ECT in chronic pain. Whether the reported improvements in the multiple somatic symptoms like in this report could be correlated with other neurobiological changes post-ECT will require further investigations. Along with pharmacotherapy and ECT, patients may require long-term, multifaceted treatment, and supplementing the same with mindfulness-based therapy or yoga therapy might prove effective in improving their overall quality of life. Overall, no single approach will effectively treat all patients with these persistent somatic symptoms in primary care. Developing a patient-centered clinical approach with a comprehensive treatment plan can contribute to the welfare of these patients and their family members.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kapfhammer HP. Somatic symptoms in depression. Dialogues Clin Neurosci 2006;8:227-39.
Waza K, Graham AV, Zyzanski SJ, Inoue K. Comparison of symptoms in Japanese and American depressed primary care patients. Fam Pract 1999;16:528-33.
Simon GE, VonKorff M, Piccinelli M, Fullerton C, Ormel J. An international study of the relation between somatic symptoms and depression. N
Engl J Med 1999;341:1329-35.
Burton C, McGorm K, Weller D, Sharpe M. Depression and anxiety in patients repeatedly referred to secondary care with medically unexplained symptoms: A case-control study. Psychol Med 2011;41:555-63.
Mitchell P, Torda T, Hickie I, Burke C. Propofol as an anaesthetic agent for ECT: Effect on outcome and length of course. Aust N
Z J Psychiatry 1991;25:255-61.
Hickey DR, O'Connor JP, Donati F. Comparison of atracurium and succinylcholine for electroconvulsive therapy in a patient with atypical plasma cholinesterase. Can J Anaesth 1987;34:280-3.
Kadiyala PK, Kadiyala LD. Anaesthesia for electroconvulsive therapy: An overview with an update on its role in potentiating electroconvulsive therapy. Indian J Anaesth 2017;61:373-80.
] [Full text]
Pereira CE, Pham P. Comparison of methohexital and propofol anesthesia in electroconvulsive therapy: The ideal agent. US Pharm 2014;39:36-9.
Ding Z, White PF. Anesthesia for electroconvulsive therapy. Anesth Analg 2002;94:1351-64.
Dukart J, Regen F, Kherif F, Colla M, Bajbouj M, Heuser I, et al.
Electroconvulsive therapy-induced brain plasticity determines therapeutic outcome in mood disorders. Proc Natl Acad Sci U S A 2014;111:1156-61.
Takano H, Motohashi N, Uema T, Ogawa K, Ohnishi T, Nishikawa M, et al.
Changes in regional cerebral blood flow during acute electroconvulsive therapy in patients with depression: Positron emission tomographic study. Br J Psychiatry 2007;190:63-8.
Hilton L, Hempel S, Ewing BA, Apaydin E, Xenakis L, Newberry S, et al.
Mindfulness meditation for chronic pain: Systematic review and meta-analysis. Ann Behav Med 2017;51:199-213.
[Table 1], [Table 2]