Electroconvulsive therapy in older adults.

W. Bogan Brooks, MD CAse Your patient is a 78 year old widowed woman with a history of hypertension, hyperlipidemia, osteoporosis, and major depressive disorder. She was doing well on verapamil, hydrochlorothiazide, aspirin, atorvastatin, calcium with vitamin D, nortriptyline, and trazodone until the death of her brother. During a family squabble over the allocation of the brother’s assets, your patient develops chest pain, diaphoresis, and left arm heaviness & numbness. She is admitted to a hospital where workup including cardiac isoenzymes and dobutamine stress test is negative. She is discharged with a diagnosis of Atypical Chest Pain and referred for psychotherapy. Over the next few months, your patient develops poor sleep and low appetite. She can’t concentrate to pay her bills, and stops going to the senior center for aerobics classes. She believes she is dying, fears being alone, and starts relentlessly telephoning you, her therapist and her son. You switch her from nortriptyline to mirtazepine, but she only gets worse. When you see the patient with her son in your office, she is contemplating suicide. Her son asks, “Isn’t there anything you can do to help my mother?” Since your patient has failed trials of medication & psychotherapy and is suicidal, you refer her to a geriatric psychiatry inpatient unit for electroconvulsive therapy.