Case Presentation
My presentation was on a 66 y/o Cuban female diagnosed with PMH of DM, HTN, HLD, and a PPH of Bipolar Disorder, Depressive type. I decided to present this patient because she has been in the inpatient unit for over 200 days. The patient has a hx of a suicide attempt at home as well as one in the hospital using cardiac monitor cables in an attempt to strangle herself. During the presentation, the patient is lying in bed, refusing to use words, ignoring when someone is talking to her and does not leave the bed.
Differential diagnosis:
Bipolar I Disorder, most recent episode depressed – Patient currently presents with markedly depressive symptoms (dysphoric affect, low appetite, poor energy, psychomotor retardation, soft speech, hopelessness, anhedonia, and multiple recent suicide attempts). Per history, the patient has multiple prior hospitalizations for manic episodes and was treated with Lithium.
Major Depressive Disorder – M.T. displays a depressed mood nearly every day, has loss of interest or pleasure in almost all activity nearly everyday. M.T. weight has reduced since admission M.T. also displays psychomotor retardation while eating or walking to the bathroom. She is on a 1:1 watch 24 hours of the day for fall risk. M.T. notes fatigue most of the day. M.T. notes she often has trouble sleeping. However, patient has had multiple episodes of suicide attempts including while in the hospital.
Persistent Depressive Disorder (Dysthymia) – Patient has been in the Psychiatric Inpatient Unit for 6 months. While dysthymic disorder cannot be confirmed until 2 years, the patient shows little to satisfactory improvement when asked about mood, and when visualized on exam despite treatment.
Assessment
M.T. is a 65 y/o Female who is divorced, of Cuban heritage, has two adult sons, retired, domiciled alone with a PMH of DM, HTN, HLD and a PPH of Bipolar Disorder, Depressive type. Patient is uncooperative with psychiatric evaluation and refuses to answer questions verbally.
Plan:
Patient should be on 1:1 watch for suicide and fall risk. Patient must maintain a diabetic diet. M.T. should have vitals taken per unit routine by nurses and may ambulate when tolerated. Patient is to continue her scheduled medications. Instruct nurses to bathe patient, wash hair, and change foley catheter or call urology if needed. Patients will have arrangements to be discharged to a sub-clinical acute rehabilitation per social worker.
Discourse:
Patient is scheduled for possible discharge on Monday (5/22) to a subacute rehab facility.
Article Presentation
My article is titled ” Electroconvulsive Therapy (ECT) as first-line in treatment-resistant Depression”. The article is an overall review of ECT; its main point is ECT is perhaps not used enough in treatment-resistant depression. The article states that many clinicians do not recommend ECT because of the negative stigma. Patients also are not comfortable with the procedures due to media portrayal of ECT but it is known to be helpful and may even serve as the first line for patients with treatment-resistant depression
The review states that there is a large body of studies showing comparing ECT to other treatments and in terms of efficacy of response, assessed by the Hamilton Depression Rating Scale, Montgomery-Asberg Depression Scale, or Clinical Global Impression, there was a 50% reduction in scores from baseline.
The article also goes over ECT effects, safety, and tolerability. It cautions patients with pre-existing, severe complications of cardiovascular disease due to adverse effects such as temporary blood pressure elevation and cardiac arrhythmias. More side effects include nausea and vomiting, headache, dizziness, muscle pain, drowsiness, and insomnia in geriatric patients.
The article concludes that there is evidence of ECT supporting the suggested hypothesis. Most of the side effects of ECT are mild and most are transient. There is also a low relapse rate in comparison to other treatments.
In addition, during my article presentation, Dr. Saint Martin shared his opinion. He believes ECT should be used more and it is unfortunate that it is portrayed in movies and television as an “experiment”.
