Psychosomatics 46:244-249, June 2005
© 2005 The Academy of Psychosomatic Medicine
Major Depression and the Use of Electroconvulsive Therapy (ECT) in Lung Transplant Recipients
Geetha Jayaram, M.D., M.B.A., and
Andy Casimir, M.D.
Received Oct. 2, 2003; revision received Aug. 6, 2004; accepted Sept. 13, 2004. From the Department of Psychiatry, The Johns Hopkins Hospital. Address correspondence and reprint requests to Dr. Jayaram, The Johns Hopkins Hospital, Department of Psychiatry, 600 North Wolfe St., Baltimore, MD 21287.
|
ABSTRACT
|
The purpose of this study is to describe the potential risks and benefits of electroconvulsive therapy (ECT) for treatment of depression in lung transplant recipients. The authors performed a record review of depressed patients who underwent lung transplantation at Johns Hopkins Hospital and evaluated their treatment, including ECT. In 9 years, 131 lung transplants were performed, and four patients had been diagnosed with major depression. Of those, two were candidates for ECT, and one received it. This patient’s depression did abate with ECT. ECT, an effective treatment for depression, remains a treatment method of choice for depression in the posttransplant population.
|
INTRODUCTION
|
Chronic lung disease remains the fourth leading cause of death.1 It is estimated that in approximately 20 years, it will become the third leading cause of death, surpassing stroke. As a result of the increasing number of those suffering from chronic lung disease, the number of patients requiring lung transplantation has also substantially increased.2 Lung transplantation has been shown to dramatically improve the physical status and quality of life of severely ill patients.3 Past research has focused on psychiatric manifestations after organ transplantation and has indicated that large numbers of patients suffer from various forms of psychiatric illness, including major depression, during the posttransplant period.4
Attempts made to assess the population of pretransplant patients found that 50% of candidates for lung transplantation had a diagnosable psychiatric disorder.5 Singer et al.6 assessed personality profiles of lung transplant candidates and noted that somatic, anxiety, and affective symptoms are often present in this patient population.
Given this fact, and in light of the large impact that chronic lung disease has on our population, it behooves the psychiatric field to assess this patient population for psychiatric care. For example, Thoren7 has reported a high comorbidity between asthma and anxiety disorders, and others8,9 have reported the link between chronic obstructive pulmonary disease and affective disorders. Yet other reports have attempted to describe the psychological impact of such illness on the lives of patients. For example, Coffman10 assessed the psychodynamic aspects of pulmonary disease on patients.
Although affective disorders have been noted in patients with chronic lung disease, including in those requiring transplantation, it is unclear whether screening techniques are currently used to detect comorbid affective conditions in daily practice. In addition, the treatment of such cases is often felt to be problematic. When a patient with debilitating chronic lung disease presents with major depression, physicians remain uncertain about which course of treatment is most beneficial. Both pre- and posttransplant patients are prescribed numerous medications for their illnesses, making the addition of psychiatric medications more difficult, since these may increase the risk of serious drug interactions. ECT remains an alternative and effective treatment for major depression. While Rabheru11 found that ECT remains a safe and effective treatment in medically ill populations, concern exists that this treatment is too dangerous and controversial for patients suffering either from the effects of incapacitating lung disease or the sequelae of lung transplantation.
The purpose of this article is to present a case history of depression diagnosed in a lung transplant patient at a large academic center and to review the adequacy and safety of treatment methods used, which included ECT.
|
METHOD
|
We obtained information about all lung transplantation procedures performed at Johns Hopkins Hospital over a 9-year period (1993–2002). Using past records, we compiled a database with all relevant information on lung transplant patients: diagnosis, date of transplant, side of transplant (right/left/bilateral), current status (alive or deceased), and number of survival days. We cross-referenced this list with a hospital database listing diagnoses associated with hospitalized patients. We examined these databases to find patients that had both undergone lung transplantation and been diagnosed with depression.
In addition, we evaluated concurrent psychiatric records to find all those who had received transplantation and had been admitted to the inpatient psychiatric unit at Johns Hopkins Hospital or had been seen by the general hospital psychiatry consultation service.
Because no identifying patient information was used in compiling data needed for our study and our review was part of a performance improvement audit, it was exempt from review by the Institutional Review Board (IRB). A notification of such exemption was received from the IRB.
Once we had compiled a list noting patients who had undergone lung transplantation and been evaluated for depression by psychiatrists at Johns Hopkins Hospital, we examined hospital records to determine 1) the methods by which patients were diagnosed with depression and 2) the modes of treatment and possible complications.
|
RESULTS
|
In the 9-year period evaluated, 131 patients (58 men and 73 women) received lung transplants at Johns Hopkins Hospital. Patients underwent single-lung transplants (N=74), double-lung transplants (N=54), or heart and lung transplantation (N=3). The average age at the time of the transplant procedure was 55 years (SD=8) for those receiving a single-lung transplant, 36 years (SD=14) for double-lung transplant patients, and 46 years (SD=6) for those who underwent heart and lung transplantation. Patients waited an average of 396.7 days for transplantation after being placed on the appropriate list. At the time of this study, mean survival time was 687.8 days.
In total, of the 131 patients who received transplants at Johns Hopkins Hospital from 1993 to 2002, four had a documented diagnosis of depression. Diagnoses were made by attending psychiatrists in the Department of Psychiatry at Johns Hopkins Hospital via assessment of the patient’s psychiatric history as well as in-depth clinical interviews modeled after the Structured Clinical Interview for DSM-III-R. Of the four patients diagnosed with depression, one had been treated solely with antidepressant medication, one with antidepressants and a brief admission to a chronic pain center, one with intensive inpatient psychiatric admission, and one with ECT. Because details of rationales for medication and other treatment choices were not clearly documented in the charts for all of the patients, we chose to describe the treatment course for the patient who received ECT.
Mr. A was a 55-year-old Caucasian man with a history significant for idiopathic pulmonary fibrosis, alcoholism, and depression who initially came to the attention of the psychiatry department when he was admitted to the chronic pain inpatient service. The patient had endured left single lung transplantation. The patient’s postoperative course was complicated by prolonged intubation, numerous infections, and anoxic brain injury during a period of trial extubations. In an attempt to improve the patient’s worsening mood symptoms, his psychiatrist prescribed fluoxetine. This was soon discontinued before the completion of an adequate trial of the medication because of intolerable side effects. The patient was next placed on a regimen of buproprion and methylphenidate in an attempt to help with his depression and low energy. This combination proved somewhat effective. Haloperidol at a low dose was also added, primarily to help regulate the patient’s sleep.
After developing an L1 compression fracture, the patient also exhibited symptoms suggesting major depression. As a result, the general hospital psychiatry service was asked to consult on this patient. He was subsequently transferred to the inpatient chronic pain service for evaluation and treatment of his pain and depressive symptoms. Venlafaxine was substituted for the buproprion/methylphenidate combination, which because of continued residual depression was felt to be no longer effective (although the patient had remained on this combination for weeks). Although the patient seemed to show some improvement with venlafaxine, it was ultimately discontinued for fear it might be contributing to his developing syndrome of inappropriate secretion of antidiuretic hormone (SIADH). During this admission, it was felt that the patient was somewhat delirious secondary to his numerous medications. Because of his chronic pain, he had initially been receiving numerous medications in addition to the methylphenidate and buproprion, such as zolpidem tartrate, carisoprodol, and oxycodone hydrochloride. After resolution of his delirium, Mr. A seemed less depressed and eventually stable for discharge. It was unclear which medications were contributory in causing delirium.
The patient was seen for some time by his outpatient psychiatrist, and reportedly his depressive symptoms had somewhat subsided. During a subsequent admission to the department of medicine, the patient was noted by the medical team to be tearful, cachectic, and notably nihilistic. He began stating that he wanted to "throw in the towel." He admitted that if he had the option of taking a pill to end his life, he would do so. After the initial interview by the consulting psychiatric resident and attending physicians, a diagnosis of severe major depression was made. It was felt that the patient was at high risk for self-harm and would benefit from treatment with ECT. The medical team felt that the patient, although fairly medically ill, was stable enough to undergo ECT treatment and the accompanying anesthesia. Also, numerous previous attempts at treating the patient with antidepressants had only been partially successful, and ECT was recommended as a relatively rapid solution.
The patient received five right unilateral ECT treatments that resulted in motor seizures ranging from 25 to 40 seconds, with no complications. After his second treatment, the patient appeared alert and oriented but was frequently complaining, stating that he wanted to go home. The team and the patient’s family stated that the patient looked better despite this complaining. They based this opinion on the fact that the patient was actually more invested in going to an acute rehabilitation facility so that he could eventually go home. He reported to the team after the second ECT treatment that "giving up is not an option." The consulting psychiatrist found the patient to be more conversant. His affect was brighter, but he still endorsed occasional suicidal ideation and a passive death wish.
After the third treatment, the patient was "clearly brighter with increased energy." He did still exhibit occasional weeping but stated that he was hopeful that he would continue to improve and that he was motivated to continue treatment for both his physical condition and for his mood. After the fourth treatment, the hospital course was complicated by an episode of severe dyspnea and subsequent anxiety on the day before the fifth treatment. The dyspnea soon abated, and the patient was seen as stable to go for a fifth treatment.
After the fifth treatment, the treatment team felt there was a palpable improvement in his mood. More ECT treatments were planned at that time. However, the patient’s medical condition began to worsen, and the sixth treatment was postponed. The next day, he became increasingly tachypneic, tachycardic, and febrile. It was believed that the patient had possibly developed aspiration pneumonia during the night. At that time, the patient felt rundown and was tearful at times, but this was felt to be a direct result of the sudden exacerbation of pulmonary symptoms.
After a brief period of worsening symptoms, he expired as a result of respiratory failure and possible pulmonary infection. Thorough evaluation of this case by various medical professionals resulted in the consensus that the patient’s death was due to the gradual chronic worsening of his lung disease (even posttransplant). Both the treating teams and his family agreed that ECT greatly improved his mood. Aspiration due to ECT was not documented as a direct cause.
|
DISCUSSION
|
Several points for discussion emerged from reviewing and evaluating the charts of lung transplant patients treated for depression, as well as from assessing the safety of ECT for these patients.
Risk of Depression
It has been established in the literature that there is a substantial risk of affective disorder in posttransplant patients.12,13 Given that major depression is a highly prevalent disorder among the medically ill,14 it is unlikely that only four patients of a population of 131 would exhibit depressive symptoms. This may be indicative of inadequate screening for depression in this population.
Previous work has described posttransplant depression in patients who are candidates for hepatic15 and renal16 transplantation. We feel this holds true for lung transplantation patients as well.4 Fukunishi reported the incidence of such disorders as being higher in liver than in kidney transplantation patients.13 Depression in cardiac transplantation patients has also been thoroughly reviewed.17 Some researchers have reported a high risk of major depression within 3 years of transplantation.12 Craven noted depression occurring in the context of a prolonged postoperative course with multiple complications.5 Woodman et al. reported that the prevalence of psychiatric disorders in this population ranges from 40%–70%.18 The consensus is that posttransplant depression is as possible and insidious for those receiving lung transplants as those with other forms of organ transplantation.
Although there has been work looking into the affective manifestations in this subset of patients, the literature remains very limited. A literature search yielded little about the incidence of depression in the lung transplant population. Those who have looked at the lung transplant population assert this remains true, but the data to back up this assertion are lacking. Further research should look into clarifying the actual incidence of depression in this population so as to minimize the risk of missing such cases in clinical practice. In addition, the pre- and posttransplant psychiatric evaluation schema should be reassessed in light of this information so as to assert that adequate numbers of patients with depressive illness are found and treated. We recommend using the Beck Depression Inventory19 for its clinical utility. It has been used in primary care. The Inventory for Depressive Symptomatology20 adds a clinician-administered section, does include somatic features, and requires training to use. The resolution of symptoms needs to be documented by repeated administration.
Medication Choices
A second issue for review is the consideration of medication treatment strategies. In the case we have highlighted, the patient was seriously impaired as a result of his psychiatric illness. Antidepressants have been used in this population with adequate results. Initially fluoxetine was chosen. Selective serotonin reuptake inhibitors (SSRIs) have been shown to be an effective strategy for treatment of depressive symptoms in transplant patients, although the dose must be carefully adjusted in accordance with renal and hepatic impairment. Some studies have reported citalopram and escitalopram having the least risk of drug-drug interactions. It is unclear what precise "side effects" the patient was experiencing with fluoxetine, but the possibility of a drug interaction should be considered in addition to the basic side effect profile associated with this medication.
After an initial attempt of treatment with fluoxetine, a combination treatment of buproprion and methylphenidate was attempted. It was noted by the treating physicians that this combination (for a brief period of time) was beneficial to the patient. The use of methylphenidate has been documented in the literature as a viable adjunct to treatment in certain cases. Lavretsky and Kumar21 described its effectiveness in accelerating treatment of depression in the geriatric population. Rozans et al. reported that adjunctive treatment with methylphenidate is highly effective in the care of depressed cancer patients.22 When this medication regimen is assessed in terms of a population with severe respiratory disease, it also seems safe and effective. Ayache and Junior23 described a case of severe depression in a patient with severe respiratory insufficiency and showed the effectiveness and safety of adding methylphenidate to sertraline as a treatment strategy. It appears then that the medication choice in the patient in this case was quite reasonable. Unfortunately, with time, this treatment strategy did not completely resolve symptoms.
Later, venlafaxine was briefly attempted as a treatment strategy. In terms of treating the posttransplant population, this medication may be quite useful due to its low potential for cytochrome P450-mediated drug interactions. Devane et al.24 showed that venlafaxine has no significant inhibitory or inductive effect on CYP3A4. Ereshefsky and Dugan25 went on to show negligible drug interaction potential with regards to CYP2D6, CYP1A2, CYP2C19, and CYP3A4. Venlafaxine, therefore, as a medication choice in our patient would have been useful in that it is a significantly weaker inhibitor of CYP2D6 than fluoxetine. Unfortunately for this patient, SIADH developed and venlafaxine was thus discontinued for fear it might have played a causative role. Case reports linking venlafaxine and other SSRIs such as paroxetine to SIADH have been found in the literature.25–27 Thus, this medication as well was found not to be useful in this case.
The combination of buproprion and methylphenidate may potentially induce insomnia, delirium, appetite suppression, and weight loss in a debilitated patient. The question of alternative therapies becomes relevant in this population that inherently is receiving numerous medications for immunosuppression and other acute medical reasons. As seen in this case, there are occasions when adding an antidepressant to such a mixture might prove dangerous and result in medical interactions. There are also occasions in which treatment that initially seems promising might not sustain its benefits and fully treat the illness. Other methods must be available for those patients who either prove to be treatment resistant to antidepressants or are severely depressed. One such treatment for consideration is ECT.
Rationale for ECT
ECT has been used in treatment for depression for over 70 years and is an effective form of treatment of major depression,28 significantly more effective in treating depressive symptoms than pharmacotherapy.29 A 2003 meta-analysis on the subject found that ECT remains effective, as determined by pre- and posttreatment scores on depression scales.30 This study asserts this is true without notable comorbidity attributable to the ECT. Rabheru11 found that when performed in a careful and orderly environment, ECT is as effective and not significantly more dangerous in high-risk populations, including children, the elderly, pregnant women, those with cardiovascular disease, and those with pulmonary conditions. Rasmussen et al.31 looked at ECT in patients with pulmonary disorders and determined that the two main safety risks in these patients are bronchospasm and prolonged seizure/status epilepticus (in those getting theophylline). They did note, however, that if the ECT is performed with appropriate precautions, complications can be minimal.
ECT is not contraindicated in patients with old compression fractures.31,32 Also, compression fractures are no longer a common occurrence. There is a paucity of data in the current literature on the use of ECT in the population of depressed patients after lung transplant. One explanation for this is the worry about medical complications associated with the procedure in this population. However, as our case illustrates, ECT remains a viable treatment option that does benefit such patients.
In the patient described here, ECT was documented to notably improve his mood as early as the second treatment. The patient became more hopeful, future oriented, and his feeling of self-worth improved. Evaluation of this case by various medical professionals resulted in the consensus that the patient’s subsequent death was assessed to be due to the gradual chronic worsening of his lung disease. Aspiration is one possible complication that requires vigilance. The patient tolerated the ECT well. One might hesitate before attempting a trial of ECT in such a case because of the patient’s severe lung disease or because of the fact that he had a past L1 compression fracture. However, it was frequently noted by his family that the patient appeared markedly different from baseline after treatment. Serial psychiatric evaluations found his symptoms not to be indicative of mere demoralization but of major depressive disorder. Since previous treatment strategies proved incapable of alleviating his symptoms, ECT remained a logical step in the treatment algorithm. If one undertakes careful planning and administration of ECT in these medically ill patients, no serious medical sequelae need follow.
As the population with chronic lung disease grows and the number of patients who receive lung transplants increases, so will the number of patients with depressive symptoms. As a result, the psychiatric field must look at this population more closely and determine the actual incidence of such symptoms. Medical departments with an active transplant group are encouraged to reassess screening techniques so as to ensure the highest possibility of finding and treating depression in these patients. In patients with resistant depressive illness and severe pulmonary disease who cannot tolerate additional medications, treatment teams must consider the choice of ECT for complete treatment.
|
REFERENCES
|
- National Center for Health Statistics (NCHS) Vital Statistics System
- American Lung Association Fact Sheet
- Lanuza DM: Prospective study of functional status and quality of life before and after lung transplantation. Chest 2000; 118:115–122[Abstract/Free Full Text]
- Limbos MM: Psychological functioning and quality of life in lung transplant candidates and recipients. Chest 2000; 118:408–416[Abstract/Free Full Text]
- Craven J: Psychiatric aspects of lung transplant. Am J Psychiatry 1990; 35:759–764
- Singer HK, Ruchinskas RA, Riley KC, Broshek DK, Barth JT: The psychological impact of end stage lung disease. Chest 2001; 120:1246–1252[Abstract/Free Full Text]
- Thoren C: Reviewing asthma and anxiety. Respir Med 2000; 94:409–415[CrossRef][Medline]
- Centanni S: Psychological issues in the treatment of asthmatic patients. Respir Med 2000; 94:742–749[CrossRef][Medline]
- Small SP, Graydon JE: Perceived uncertainty, physical symptoms, and negative mood in hospitalized patients with chronic obstructive pulmonary disease. Heart Lung 1992; 21:568–574[Medline]
- Coffman K: Psychiatric issues in pulmonary disease. Psychiatr Clin North Am 2002; 25:89–127[CrossRef][Medline]
- Rabheru K: The use of electroconvulsive therapy in special patient populations. Can J Psychiatry 2001; 46:710–719[Medline]
- Dew MA: Prevalence and risk of depression and anxiety-related disorders during the first three years after heart transplantation. Psychosomatics 2001; 42:300–313[Abstract/Free Full Text]
- Fukunishi I: Psychiatric disorders before and after living-related transplantation. Psychosomatics 2001; 42:337–343[Abstract/Free Full Text]
- Katon W, Von Korff M, Lin E: Distressed high utilizers of medical care: DSM-III-R diagnoses and treatment needs. Gen Hosp Psychiatry 1990; 12:355–362[CrossRef][Medline]
- House R, Dubovsky SL, Penn I: Psychiatric aspects of hepatic transplantation. Transplantation 1983; 36:146–150[Medline]
- Sensky T: Psychiatric morbidity in renal transplantation. Psychother Psychosom 1989; 52:41–46[Medline]
- Lee HB, Jayaram G, Teitelbaum ML: Electroconvulsive therapy for depression in a cardiac transplant patient. Psychosomatics 2001; 42:362–364[Free Full Text]
- Woodman CL, Vance S, Jones K: Psychiatric disorders and survival after lung transplantation. Psychosomatics 1999; 40:293–297[Abstract/Free Full Text]
- Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J: An inventory of measuring depression. Arch Gen Psychiatry 1961; 4:561–571
- Rush AJ, Giles DE, Schlesser MA, Fulton CL, Weissenburger J, Burns C: The Inventory for Depressive Symptomatology (IDS): preliminary findings. Psychiatry Res 1986; 18:65–87[CrossRef][Medline]
- Lavretsky H, Kumar A: Methylphenidate augmentation of citalopram in elderly patients. Am J Geriatr Psychiatry 2001; 9:298–303[CrossRef][Medline]
- Rozans M, Dreisbach A, Lertora JJL, Kahn M: Palliative uses of methylphenidate in patients with cancer: a review. J Clinical Oncology 2002; 20:335–339
- Ayache DC, Junior RF: Methylphenidate in a patient with depression and respiratory insufficiency. Int J Psychiatry Med 2001; 31:443–449[CrossRef][Medline]
- Devane CL, Donovan JL, Liston HL, Markowitz JS, Cheng KT, Risch SC, Willard L: Comparative CYP3A4 inhibitory effects of venlafaxine, fluoxetine, sertraline, and nefazodone in healthy volunteers. J Clin Psychopharmacol 2004; 24:4–10[CrossRef][Medline]
- Ereshefsky L, Dugan D: Review of the pharmacokinetics, pharmacogenetics, and drug interaction potential of antidepressants: focus on venlafaxine. Depress Anxiety 2000; 12(suppl 1):30–44
- Maynaar IA, Peeters AJ, Mulder AH, Ottervanger JP: Syndrome of inappropriate ADH secretion attributed to the serotonin re-uptake inhibitors, venlafaxine and paroxetine. Neth J Med. 1997; 50:243–245
- Masood GR, Karki SD, Patterson WR: Hyponatremia with venlafaxine. Ann Pharmacother 1998; 32:49–51[Abstract/Free Full Text]
- Izzedine H, Launay-Vacher V, Ciroldi M, Fardet L, Deray G: Fanconi and inappropriate secretion of antidiuretic hormone syndromes secondary to venlafaxine therapy. Nephron 2002; 92:944–946[CrossRef][Medline]
- Fink M: ECT has proved effective in treating depression. Nature 2000; 403:826[Medline]
- UK ECT Review Group: Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis. Lancet 2003; 361:799–808[CrossRef][Medline]
- Rasmussen KG, Rummans TA, Richardson JW: Electroconvulsive therapy in the medically ill. Psychiatr Clin North Am 2002; 25:177–193[CrossRef][Medline]
- American Psychiatric Association: The Practice of Electroconvulsive Therapy: A Task Force Report, 2nd ed. Washington, DC, APA, 2001
This article has been cited by other articles:
|
|
|
|
 
H. W. Goforth and K. G. Shiry
Electroconvulsive Therapy for Severe Major Depressive Disorder After Orthotopic Liver Transplantation * Case Report
Psychosomatics,
May 1, 2008;
49(3):
271 - 272.
[Full Text]
[PDF]
|
|
|
Get information about faster international access.
Privacy Policy
Copyright © 2005
Academy of Psychosomatic Medicine.
All rights reserved.
Home
| Search
| Current Issue
| Past Issues
| Subscribe
| All APPI Journals
| Help
| Contact Us
|
TOP
ABSTRACT
INTRODUCTION
