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Electroconvulsive Therapy for Severe Major Depressive Disorder After Orthotopic Liver Transplantation • Case Report

Key Words: Liver Transplantation • ECT • Depression

TO THE EDITOR: Depression is one of the more common neuropsychiatric presentations after liver transplantation.^1–3 In addition to its potential to cause significant distress and suffering to the individual, depression has been demonstrated to be a significant predictor after transplantation of a failure to return to work, suboptimal psychosocial performance, fatigue, and nutritional decline.^4–6 However, few guidelines are available to guide practitioners in the treatment of posttransplant depression—especially when the presentation is severe and life-threatening. This report illustrates the role that ECT (electroconvulsive therapy) can play in severely depressed, medically complicated patients.

The patient is a 57-year-old woman with a past history of orthotopic liver transplantation (OLT) for primary biliary cirrhosis, with a significantly complicated postoperative course over the next 30 days, including a hepatic artery thrombosis resulting in a loss of the initial graft and requiring a second OLT 3 weeks after the first. The patient was discharged from the hospital to a rehabilitation facility after the second transplant, but was readmitted for complaints of low back pain and diarrhea, which were attributed to a T11 compression fracture and recurrent C. difficile colitis. She was also noted to be depressed, with a significantly diminished appetite that required tube-feed supplementation, and a psychiatrist was consulted who initiated mirtazapine 15 mg nightly.

Approximately 1 month after this encounter, she presented to the transplantation clinic for a routine clinic follow-up visit and was noted to have elevated liver enzymes, which prompted admission for a liver biopsy and immunosuppressant adjustment. During this time-period, her mood declined such that it was interfering with her ability to participate in activities of daily living, so Psychiatry was again consulted. The patient demonstrated marked psychomotor retardation, with near-complete immobility, paucity of speech, and refusal of all food and drink. Her total nutritional needs were being sustained by use of tube-feeds via a jejunostomy. She displayed prominent anhedonia, staring, and avolition, with slowed thought-processes. Her thought content was notable for delusions of persecution involving both her primary caregivers as well as the nursing staff and former co-workers. Bitemporal ECT was begun 3 days later (4 months after the second OLT) because of the severity of her depressive illness.

The patient received a total of 10 bitemporal treatments over 26 days, with a gradually increasing stimulus intensity, to reach parameters of 1-msec pulse width, 60-Hz frequency, 6-sec stimulus duration, and 0.8 amperes by the ninth treatment. The electrical stimulus was administered no sooner than 2 minutes after the succinylcholine and after extermination of an ankle jerk response, using a peripheral nerve stimulator to ensure maximal paralysis, given the presence of recent vertebral fractures. She responded well to ECT, with a corresponding decline in her Montgomery-Asburg Depression Rating Scale (MADRS) from 52 (baseline) to 6 (remission) immediately before her final index treatment. Self-care, appetite, and psychomotor retardation all dramatically improved over the course of ECT. She was discharged home in stable condition without tube-feeds, with psychiatric follow-up arranged with a member of the Consultation–Liaison team.

Discussion

In spite of the fact that major depressive syndromes may affect up to 10% of OLT patients, there is a paucity of available literature concerning the treatment of severe depression after liver transplantation. Published literature concerning somatic treatments of posttransplant depression is limited to a single open-label trial of citalopram⁷ and case reports of psychostimulant or ECT use.^8,9 However, as noted in this case, depression in severely medically ill individuals can be a life-threatening emergency, and ECT remains an important consideration when suicidal concerns are imminent or the patient has not responded to pharmacotherapy trials. The use of ECT after both cardiac and lung transplantations has been described for use in severely depressed patients,^10–13 and its use has been noted to be safe and effective in these cases. Similarly, this case report supports the available literature that ECT can be a valuable and life-saving treatment for depression even in severely medically ill organ transplant recipients.

REFERENCES

1. Trzepacz PT, Brenner R, Van Thiel DH: A psychiatric study of 247 liver transplantation candidates. Psychosomatics 1989; 30:145–153
2. Caccamo L, Azara V, Doglia M, et al: Longitudinal prospective measurement of the quality of life before and after liver transplantation among adults. Transplant Proc 2001; 33:1880–1881[CrossRef][Medline]
3. O’Carroll RE, Couston M, Cossar J, et al: Psychological outcome and quality of life following liver transplantation: a prospective, national, single-center study. Liver Transpl 2003; 9:712–720[CrossRef][Medline]
4. Newton SE: Relationship between depression and work outcomes following liver transplantation: the nursing perspective. Gastroenterol Nurs 2003; 26:68–72[CrossRef][Medline]
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7. Liston HL, Markowitz JS, Hunt N, et al: Lack of citalopram effect on the pharmacokinetics of cyclosporine. Psychosomatics 2001; 42:370–372[Free Full Text]
8. Plutchik L, Snyder S, Drooker M, et al: Methylphenidate in post-liver transplant patients. Psychosomatics 1998; 39:118–123[Abstract/Free Full Text]
9. Showalter PE, Young SA, Bilello JF, et al: Electroconvulsive therapy for depression in a liver transplant patient (letter). Psychosomatics 1993; 34:537[Medline]
10. Lee HB, Javaram G, Teitelbaum ML: Electroconvulsive therapy for depression in a cardiac transplant patient. Psychosomatics 2001; 42:362–364[Free Full Text]
11. Bloch M, Admon D, Bonne O, et al: Electroconvulsive therapy in a depressed heart transplant patient. Convuls Ther 1992; 8:290–293[Medline]
12. Kellner CH, Monroe RR, Burns C, et al: Electroconvulsive therapy in a patient with a heart transplant (letter). N Engl J Med 1991; 325:663[Medline]
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