ECT TREATMENT WAS EFFECTIVE AND SAFE FORSENILE VASCULAR DEPRESSION: TWO CASES REPORT1111Youhei Tomita, MD , Akio Mantani, MD, PhD , Makoto Hayashi, MD , Yoshikazu Masuda, MD ,122Naofumi Tarumoto, MD , Hidehisa Yamashita, MD, PhD , Shigeto Yamawaki, MD, PhD
1Department of Psychiatry, Yoshida General Hospital, Akitakata-shi, Hiroshima, Japan
2Department of Psychiatry and Neurosciences, Division of Frontier Medical Science, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, JapanIntroduction
Electroconvulsive therapy (ECT) should be used carefully for senile patients because of its
side effects, while ECT has the advantage of acute response to therapy compared withpharmacotherapy. Tew et al. reported that even the oldest patients (over 75 years old) withsevere major depression tolerate ECT in a manner similar to that for younger patients anddemonstrate similar or better acute response, despite a higher level of physical illness andcognitive impairment (1) . The depression associated with cerebral infarction (vasculardepression, VD) is more resistant to treatment than that without cerebral infarction. There
are relatively few data addressing the outcome of ECT for senile patients, especially over
80 years of age.
We observed that two senile patients of VD were immediately responded to ECT and
improved the symptoms. They showed no remarkable adverse reactions of ECT.

Figure 1: Time course of Case1
Head CT of case 1 on admission
psychomotor
retardation
hypochondria

dietary intake

Case 1
A 81-year-old woman with history of hypertension was admitted to the psychiatric inpatient
unit at our hospital for evaluation and treatment of depression. She was married and retired,living with her husband. After her husband met a traffic accident, she had gradually become
depressed 3 months before admission. She was treated with amoxapine (100mg/day) in a
outpatient clinic, but failed to respond. Subsequently she was referred to our hospital forevaluation and medication.
Her past psychiatric history and her family history was negative. The head CT showed rightoccipital old infarction (Figure 1). Hamilton Depression Scale (HAM-D) was 27. Onadmission, she had morbid ideas and said ”I might be seriously wounded like my husband.”“My husband might be died and I become alone.” She was treated with amoxapine(100mg/day) and olanzapine (2.5mg/day), but failed to respond, tended to refuse meals,
had been lying in her bed all day, so the risk of articular contracture increased. We
concluded that administration of ECT was required in order to rapid improvement of her
depressed symptoms. After providing informed consent, she underwent a course of 10 brief
pulse bilateral (frontotemporal) ECT treatments. The ECT was initiated using Thymatron
System Ⅳ twice a week with 40%～100％ stimulation doses.
She recovered promptly without critical side effects, and became able to eat and walk in
the ward with smile. She was discharged on the 175th day after admission. After discharge,
the patient was in remission from depression and continued recovering while taking
amoxapine (75mg/day) and mirtazapine (22.5mg/day).

Case 284-year-old woman with history of diabetes mellitus、hypertension、hyperlipidemia wasadmitted to the psychiatric inpatient unit at our hospital for evaluation and treatment ofdepression. She was married and retired, living with her son’s family. She had experienced
her first depressive episode 8 years before admission and had treated by approximately
one-year in an psychiatric hospital. After discharge, she got outpatient treatment inremission with paroxetine (40mg/day) and sulpiride (150mg/day) in a nearby clinic regularly.
Eight years later, she became depressed again and had paranoia and hallucination. She
said “I can hear the wire broadcasting all the time.” ”I have money stolen from a person ofthe religion. I am murdered.” Subsequenetly, she was referred to our hospital for evaluationand medication.
Her family history was negative. The magnetic resonance imaging (MRI) revealed
multiple lacunar infarction and periventricular ischemic lesion (Figure 2). Revised
Hasegawa’s dementia scale (HDS-R) score was 12/30 at the time of admission. We
suspected delirium related to antidepressant and discontinued paroxetine. Her delirium
improved but her depression worsened. She was treated with milnacipran but failed torespond. Her dietary intake decreased and she became stuporous. After providing informed
consent, she underwent a course of 8 brief pulse bilateral (frontotemporal) ECT treatments.
The ECT was initiated using Thymatron System Ⅳ twice a week with 40% ～ 60 ％stimulation doses.
She recovered promptly without critical side effects, and became able to eat.
Hallucinations and delusions disappeared. She was discharged on the 99th day afteradmission. After discharge, the patient was in remission from depression and continued
recovering while taking sulpiride (100mg/day) and milnacipran (150mg/day).

Discussion
Wilkinson et al. reported that dividing subjects into above and below 65years age andcomparing response to ECT showed that 19 of 35 (54%) in the younger group and 31 of 43
senile patients (73%) made a positive response(2). Tew et al. also reported that the adult(59 and younger) patients experience a significantly lower rate of ECT response (54%) than
the young-old (60 to 74 years) patients (73%), while the old-old (75 and older) patients had
an intermediate rate of response (67%)(1). Moreover, O’cConnor et al. found ECT to besignificantly more effective in patients older than 65 years compared with patients younger
than 45 years(3).
On the other hand, how is tolerance? Damm et al. reported that transient cardiovascularadverse effects and cognitive disturbances were more frequent in the elderly, but in mostcases, there was no need for any specific treatment(4). Hausner et al. reported thatcognitive side effects after ECT were reversible and transient, even in dementia subjects,
and, preexisting cognitive deficits were the best clinical predictor of a reversible cognitive
decline(5). In senile depressive subjects, high-dose right unilateral ECT is as effective as
bilateral ECT yet produces less adverse effects and less cognitive impairment(6).
As Alexopoulos and Krishnan advocated the concept of VD(7)(8), when we treat depressed
senile patents, it is necessary to consider the depression caused by cerebrovasculardisorder. VD require longer hospital treatment and have more drug-related adverse
reactions of the central nervous system (delirium, parkinsonism, dyskinesia, akathisia)(9).
Therefore, ECTs are performed in treatment-resistant cases and in cases that require
urgent improvement.

Hamilton Depression
Scale(HAM-D)

30

Hasegawa’s
dementia scale(HDS-R)

30271582428

1525

21amoxapine(mg)100mianserin(mg)10olanzapine(mg)25

day 07590

150

admissiondischarge

ECTFigure 2: Time course of Case2
Head MRI of case 2 on admission
delirium
stupordietary intake
HAM-D

HDS-R
paroxetine(mg)

30
530

1530

1229

1520

10sulpiride(mg)milnacipran(mg)day 0admission

1001502550

753060ECT90

discharge

Conclusions
We showed 2 cases of senile VD patients who had inadequate response to antidepressanttreatments and significantly improved by ECT without critical side effects. According toprevious literatures and our cases, ECT may be useful for senile patients with VD.

References
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