When ECT fails…then what?

[randomdoc1]

Bipolar I female in 70s. hx MDE with psychosis and catatonia. Stable for decades on lithium and lamictal. But past 5 years like clockwork enters MDE around fall equinox. Every year has responded to ECT beautifully. This time had 6 sessions and nada. She’s been inpatient a couple times like three years ago. Myself and multiple psychiatrists of academic centers all concur she’s definitely a bipolar I and a pretty classic presentation. Got most recent ECT from one of most reputable providers in the state who happens to know his gero psych well. I tried every fda approved bipolar depression agent. So far he hasn’t provided new insights either.

However, and I’m hoping so hard, has hx of hyper parathyroid. Interestingly, first MDE in decades started in context of prior to her getting a parathyroidectomy and she was good for two years before next MDE. There’s some evidence she may, just may (grasping at straws now), need another parathyroidectomy. She always has close outpatient medical follow up by all her providers, a true model patient. I plan to check in with endo.

Any ideas? Thoughts?

To make things worse, lithium has been her lifeline. But Cr has creeped up over the years.

I will of course keep trying. Am of course doing my own work to not take it too hard.

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[Sushirolls]

Best in state doesn't mean much...

Sure, do the general medical review and Endocrinology work up.

Don't give up on ECT yet. If needed, send to another ECT specialist. Such robust, consistent ECT results historically, likely means just needs more ECT. Yes, typically geriatric response/remit sooner, but perhaps not this time.

When I was doing my solo service, ~8.1 was average remission treatment number... that means there are people who need more.

This is a person who should definitely push to 12, and even if no response then, consider pushing to 20. Whether this is twice a week, or thrice week treatments. And if the numbers are pushing up to 12, then consider switching from placement RUL, to say BF or BFT or even BT...

Or consider the switch from RUL to BF / BFT / BT right from the start.

Been few years, but when I was doing it, there was schism of ECT with RUL and Ultrabrief RUL taking over the treatment paradigm. The BF / BFT / BT crowd was being pushed into a switch later, or if UB RUL isn't getting the results early on. Wouldn't be suprsised if the UB RUL / RUL crowd took the 'academic throne.'

 

[J ROD]

*Edited

 

[Ironspy]

I do ECT and do 10-12 treatments if no adverse effects before saying it didn’t work. If she’s not getting bilateral electrode placement I would switch to bilateral. If no response consider psychotherapy with behavioral activation and light therapy. Make sure vit D, b6, b12, folate are wnl.

 

[reca]

*edited*

Uhhhh, I assume "shag" means something else where you're from. Otherwise, this would be a pretty serious ethics violation....

 

[smalltownpsych]

A good shag can be very therapeutic. Only unethical if we’re involved in it as far as I know. I do think that they were just being a bit facetious and flip about a very complex case. Whether or not the humor was appropriate or not is always a fine line. I thought it was kind of funny. On the more serious side, environmental and behavioral interventions can have effects and if medical regimens aren’t working as well, increasing other aspects of treatment could be an option. One first line I’ll go to with chronic and serious patients is extra psychotherapy sessions with myself. That helps in numerous ways and one of those is that I will by necessity focus on all of the non-medical interventions that can be of help.

 

[esob]

If you really want to chase the Ca++/parathyroid route, you should check out Dr. James Norman's info at parathyroid.com. The TLDR, if I remember correctly, is that a large percent of pt's on chronic lithium therapy typically need re-op's at some point due to new hyperplasia.

 

[mistafab]

Don't give up on ECT yet. Average session number to response is between 6-12. Don't give up at this point on session 6.

Also, review the ECT procedure. If she is not responding, make sure they are on BL and not doing BF or RUL. Also make sure they have increased the charge.

 

[clausewitz2]

Bipolar I female in 70s. hx MDE with psychosis and catatonia. Stable for decades on lithium and lamictal. But past 5 years like clockwork enters MDE around fall equinox. Every year has responded to ECT beautifully. This time had 6 sessions and nada. She’s been inpatient a couple times like three years ago. Myself and multiple psychiatrists of academic centers all concur she’s definitely a bipolar I and a pretty classic presentation. Got most recent ECT from one of most reputable providers in the state who happens to know his gero psych well. I tried every fda approved bipolar depression agent. So far he hasn’t provided new insights either.

However, and I’m hoping so hard, has hx of hyper parathyroid. Interestingly, first MDE in decades started in context of prior to her getting a parathyroidectomy and she was good for two years before next MDE. There’s some evidence she may, just may (grasping at straws now), need another parathyroidectomy. She always has close outpatient medical follow up by all her providers, a true model patient. I plan to check in with endo.

Any ideas? Thoughts?

To make things worse, lithium has been her lifeline. But Cr has creeped up over the years.

I will of course keep trying. Am of course doing my own work to not take it too hard.

Solid suggestions so far in-thread. Behaviorally, are you guys anywhere near any of the couple of centers with triple chronotherapy protocols?

To chime in with more pharmaceutically-oriented suggestions, you mentioned FDA approved agents specifically for bipolar depression, but that leaves off a lot of possibilities. For instance, hot off the press is a new article supporting the efficacy and safety of MAOIs in bipolar depression:

https://onlinelibrary.wiley.com/doi/10.1111/acps.13518

You are obviously past the point of algorithm so I'm curious about which of the following have been tried and if so how they went:

MAOI
methylphenidate
methylphenidate + MAOI
pramipexole
nimodipine (potentially especially worth examining due to the calcium angle)
minocycline

 

[Sushirolls]

Why won't MAOI's just ... go away.

 

[clausewitz2]

Why won't MAOI's just ... go away.

They're often extremely effective?

 

[Sushirolls]

I've not seen it.

They are also rife with side effects and behavioral restrictions that patients are ready to commit to.
Younger psychiatrists like myself, didn't get enough exposure to manage the breath of this medication class or side effects.
Drug/Drug interactions of the meds aren't really known by the other specialists and considering the number of PA/ARNPs in ED/Urgent Care/Primary care, heck, everywhere, these medicines really asking for issues for the whole health system.

I suspect the iatrogenic issues in this decade, are more than the benefits.

 

[littlefred]

Whenever a treatment doesn't work, I always think that maybe I'm not treating the right thing.
ECT is one of our best treatments for melancholic depression, catatonia, bipolar disorder in manic state etc.

I personally have treated patients with personality disorders that have received ECT prior and they don't have any improvements.

 

[clausewitz2]

I've not seen it.

They are also rife with side effects and behavioral restrictions that patients are ready to commit to.
Younger psychiatrists like myself, didn't get enough exposure to manage the breath of this medication class or side effects.
Drug/Drug interactions of the meds aren't really known by the other specialists and considering the number of PA/ARNPs in ED/Urgent Care/Primary care, heck, everywhere, these medicines really asking for issues for the whole health system.

I suspect the iatrogenic issues in this decade, are more than the benefits.

In all honesty, how many people have you started on phenelzine/tranylcypromine/isocarboxazid?

We've had this conversation before and I will gesture at the previous threads, but MAOIs actually have substantially fewer drug/drug interactions than, say, fluoxetine. There is a small set of molecules that increase intra-synaptic serotonin levels that are a definite no-no, but that is really it.

Literally the only person I've worked with who had trouble the diet was a kimchi enthusiast.

 

[milesed]

Have they tried Ketamine? TMS?
There is also a psilocybin type med in trials for GAD, MDD hopefully coming out soon.

 

[Sushirolls]

In all honesty, how many people have you started on phenelzine/tranylcypromine/isocarboxazid?

We've had this conversation before and I will gesture at the previous threads, but MAOIs actually have substantially fewer drug/drug interactions than, say, fluoxetine. There is a small set of molecules that increase intra-synaptic serotonin levels that are a definite no-no, but that is really it.

Literally the only person I've worked with who had trouble the diet was a kimchi enthusiast.

I think we have had this discussion before.

 

[Desired Member]

methylphenidate + MAOI

😱

 

[clausewitz2]

😱

It's a thing.

 

[ObsequiousAplomb]

It's a thing.

I know that when I've read about this people say to do things like give the first few doses of the stimulant in the office and have rescue BP meds on hand. Is that something that's real or is that overkill and not actually done? Is it a thing for Adderall but not Ritalin? I sorta had the suspicion it was overkill, given that some of the MAOIs are metabolized into amphetamines.

 

[clausewitz2]

Methylphenidate isn't an amphetamine and TCP is not actually metabolized into an amphetamine, although that was a theory back in the day. Generally though the guidance from people who do this more frequently than I do is Ritalin, not Adderall, precisely for the BP and idea that directly promoting dopamine release might cause more to ruble than blocking DAT.

 

[Ironspy]

Have they tried Ketamine? TMS?
There is also a psilocybin type med in trials for GAD, MDD hopefully coming out soon.

Insurance does not typically pay for TMS for bipolar depression as it’s only fda approved for unipolar. Ketamine is probably less effective in the elderly but not contraindicated. Curious if insurance would pay for this.

Most psychedelic trials I’ve seen exclude >65 as well

I agree with psychotherapy as above given significant comorbidity of axis 2 in people with treatment resistant depression

 

[Stagg737]

Interesting thread @randomdoc1 , curious to hear how things go with updates.

I agree that 6 sessions of ECT may not be enough but you said she's "responded beautifully" in the past. Can you clarify what that means? How many sessions have her past courses been? Is it possible her depression came on earlier this year and was more severe on initiation than in the past which is why she is needing more sessions? Any other major psychiatric co-morbidities? Just some musings to think about.

Also, if there's truly a seasonal component, light therapy could be worth a try. Sure, you might risk inducing hypo/mania but she's on mood stabilizers and can abort if noting that. Honestly not sure about the data for patients already on a mood stabilizer flipping into manic states with light therapy, but just another thought in addition to what's already been discussed.

 

[randomdoc1]

Interesting thread @randomdoc1 , curious to hear how things go with updates.

I agree that 6 sessions of ECT may not be enough but you said she's "responded beautifully" in the past. Can you clarify what that means? How many sessions have her past courses been? Is it possible her depression came on earlier this year and was more severe on initiation than in the past which is why she is needing more sessions? Any other major psychiatric co-morbidities? Just some musings to think about.

Also, if there's truly a seasonal component, light therapy could be worth a try. Sure, you might risk inducing hypo/mania but she's on mood stabilizers and can abort if noting that. Honestly not sure about the data for patients already on a mood stabilizer flipping into manic states with light therapy, but just another thought in addition to what's already been discussed.

Thanks! Yes, by beautifully, it used to only take 3 sessions at most to see a notable difference. So this is definitely different for her. Past courses needed no more than 7 sessions before we found the plateau which was usually full remission. It's odd, once after 2 sessions of ECT she went manic. Another time when she was catatonic, we did the lorazepam thing which broke it very effectively...and she went manic with the pressured speech, increase in goal directed activity (husband left her to wait in the car one day and told her to stay put and by time he was back found her in a grocery store with a full cart rambling about a vacation home that doesn't exist), not sleeping, grandiose, definitely lost touch with reality. She's in her usual depressed state now--somatically preoccupied about being dehydrated and not eating enough. At night husband struggles but manages to get her to take meds because she fears they will kill her by the following morning, this is every time she's depressed.

Definitely wish husband would be more aggressive with the light therapy. Nothing to lose by it. But he's skeptical and does not follow through. But yet he's apprehensive of ECT too. He usually does not take her in until he's at his wits end. That or, last year I refused to see them for a follow up until they've contacted the ECT clinic and started ECT again (if the MD recommends it of course). She was so catatonic that I expressed concern of her being a DVT risk and I had a set a boundary. I've known her now for about 6 years. He keeps bugging me (yes, it's my counter transferance) to "just try another med, maybe it will perk her up". I've tried every mood stabilizer too. I've even at one point tried an MAOI (nardil--but maybe I should try another? as @clausewitz2 said, we're past the algorithm). Tried loxapine as well. No MAOI with ritalin though. Now with this round of ECT, he said for the time being he's giving up on ECT and tried to schedule another appointment with me "maybe a med change will perk her up." I responded that, med changes never have (at least under my care) and I suspect, very possibly, they never will. It just sounds so stupid--the family and I go through this every year. "not ECT yet, just try another med, just please keep trying meds if this next one doesn't work." So I coordinated with the ECT psychiatrist and got the pt and husband to follow up with him to discuss treatment planning next week, I'll be in the call via audio as well. It sounded like she may have had more of the cognitive side effects (the psychiatrist thinks this patient actually was starting to show response--husband's narrative though saw no benefit) and the ECT psychiatrist and I are thinking of continuing ECT but with more time between sessions and talking some more about the ECT technique used. He enjoys seeing this patient too and has used this case to teach medical students what bipolar I and using ECT looks like. It sounded like a combination of some more ECT side effects but also partly that husband still does not want to keep pursuing ECT and is hoping for the med route. But I'm like, totally out of meds. At least the most promising ones!

I agree, it's easier to bring someone down than up, lol! I have wondered about TMS for maintenance but there's no insurance reimbursement for that. But that angle would be very very interesting. I also agree that psychotherapy has nothing to lose and I'm not opposed. It's just hard to make progress because she keeps going back to talking about dehydration and not enough food. Then spouse chimes in with "are we gonna make a med change today?" lol

 

[clausewitz2]

I've even at one point tried an MAOI (nardil--but maybe I should try another? as @clausewitz2 said, we're past the algorithm). Tried loxapine as well. No MAOI with ritalin though.

How high was the dose of Nardil? And yes, TCP and phenelzine end up being very different experiences so definitely.

In terms of off-algorithm stuff, another possibility is supraphysiological thyroid hormone.

 

[psychmd03]

I do ECT and do 10-12 treatments if no adverse effects before saying it didn’t work. If she’s not getting bilateral electrode placement I would switch to bilateral. If no response consider psychotherapy with behavioral activation and light therapy. Make sure vit D, b6, b12, folate are wnl.

Gotta agree a lot here. I would push the ECT treatments and make sure they are BL. I just had a patient come to inpatient that got to treatment 23 when the final plateau hit. I have had a few that I got to see slowly get worse responses out of ect. Needing treatment more every 6 months- year until he needed maintenance ect every 2 week just to stop his mania and if he missed it by a few days he would be manic and need a full course. I would be curious what others think about the possibility of age-related change as well as illness-induced brain changes causing a decrease in the effectiveness of treatment.

 

[splik]

It is not uncommon for patients to need more ECT to get improvement as time goes on. Nowadays 10-12 sessions is considered standard, and some patients need 20 sessions for improvement. I also agree with above, that she needs bitemporal or bifrontal ECT if not already receiving. I wouldn't rely on the husband for input on response either. She may also benefit from receiving ECT in an inpatient setting.

I do not think psychotherapy is going to be much help for someone with this level of depression. Typically requires a very skilled therapist who is able to work with psychosis and see patient multiple times per week and those are quite rare.

Must always consider possibility of cerebrovascular disease or neurodegenerative disease complicating picture. I would suggest MRI brain to see if there is any evidence of either.

If not already done, would optimize dose of lithium (despite increasing Cr) and lamotrigine.

I would not use MAOIs for patients with this kind of depression until exhausting other options (and I am a fan of MAOIs). Patient essentially has a psychotic form of bipolar depression which means the usual antipsychotics for bipolar depression (e.g. lurasidone, quetiapine, cariprazine) are not much use. I usually go for olanzapine (with or without an antidepressant), and use clozapine if that does not work. If an SSRI or SNRI is not helpful in addition to antipsychotic, I would consider a TCA. It is not unreasonable to use methylphenidate with either an SSRI/SNRI or TCA in this situation but they need to be on a decent antipsychotic.

 

[smalltownpsych]

I do not think psychotherapy is going to be much help for someone with this level of depression. Typically requires a very skilled therapist who is able to work with psychosis and see patient multiple times per week and those are quite rare.

Good point. Sometimes I forget that i am one of those rare psychologists who does this kind of intensive work in an outpatient setting and that referral to the typical outpatient community therapist will probably do more harm than good.

 

[whopper]

If mood worsens in sync with the fall-equinox, if it's within the patient's power have them go somewhere warm and sunny for at least a few days.

SAD lamps help but they don't compare to the real thing.

 

[Desired Member]

Bipolar I female in 70s. hx MDE with psychosis and catatonia. Stable for decades on lithium and lamictal. But past 5 years like clockwork enters MDE around fall equinox. Every year has responded to ECT beautifully. This time had 6 sessions and nada. She’s been inpatient a couple times like three years ago. Myself and multiple psychiatrists of academic centers all concur she’s definitely a bipolar I and a pretty classic presentation. Got most recent ECT from one of most reputable providers in the state who happens to know his gero psych well. I tried every fda approved bipolar depression agent. So far he hasn’t provided new insights either.

However, and I’m hoping so hard, has hx of hyper parathyroid. Interestingly, first MDE in decades started in context of prior to her getting a parathyroidectomy and she was good for two years before next MDE. There’s some evidence she may, just may (grasping at straws now), need another parathyroidectomy. She always has close outpatient medical follow up by all her providers, a true model patient. I plan to check in with endo.

Any ideas? Thoughts?

To make things worse, lithium has been her lifeline. But Cr has creeped up over the years.

I will of course keep trying. Am of course doing my own work to not take it too hard.

Disclaimer - still a resident
I'm curious if lamictal has been stopped or maybe held the day of ECT? I am wondering how this might theoretically affect the treatment of her depression and how the ECT specialist is handling this.
I think Splik's remark about possibility of neurocognitive disorder is interesting, as the patient is elderly and bipolar patients are at higher risk for developing dementia.
I found it really interesting how Splik mentioned that the usual antipsychotics for bipolar depression (e.g. lurasidone, quetiapine, cariprazine) would not be very useful for psychotic form of bipolar depression. I have never heard that before.
Also never heard anything about ssri/snri's or TCA's being helpful for bipolar disorder. In my experience, bipolar patients do not benefit from antidepressants and I didn't think there was any evidence they do?
Albeit based on very limited experience, I think clozapine is a promising idea if ECT fails

 

[Psychferlyfe3000]

It is not uncommon for patients to need more ECT to get improvement as time goes on. Nowadays 10-12 sessions is considered standard, and some patients need 20 sessions for improvement. I also agree with above, that she needs bitemporal or bifrontal ECT if not already receiving. I wouldn't rely on the husband for input on response either. She may also benefit from receiving ECT in an inpatient setting.

I do not think psychotherapy is going to be much help for someone with this level of depression. Typically requires a very skilled therapist who is able to work with psychosis and see patient multiple times per week and those are quite rare.

Must always consider possibility of cerebrovascular disease or neurodegenerative disease complicating picture. I would suggest MRI brain to see if there is any evidence of either.

If not already done, would optimize dose of lithium (despite increasing Cr) and lamotrigine.

I would not use MAOIs for patients with this kind of depression until exhausting other options (and I am a fan of MAOIs). Patient essentially has a psychotic form of bipolar depression which means the usual antipsychotics for bipolar depression (e.g. lurasidone, quetiapine, cariprazine) are not much use. I usually go for olanzapine (with or without an antidepressant), and use clozapine if that does not work. If an SSRI or SNRI is not helpful in addition to antipsychotic, I would consider a TCA. It is not unreasonable to use methylphenidate with either an SSRI/SNRI or TCA in this situation but they need to be on a decent antipsychotic.

Interesting that you go for olanzapine. What is your thought process behind that?

 

[FlowRate]

Interesting that you go for olanzapine. What is your thought process behind that?

I'm sure splik would have a more eloquent and/or detailed way of saying this, but I think it's related to the psychotic piece and olanzapine (and clozapine) being the best AP's for psychosis specifically.

 

[Batman's Underwear]

Another exotic off-label tx that was not mentioned would be low dose suboxone as adjunct. Any cognitive impairment? Neurodegenerative disease can do many negative wonders, including worsening of pre-existing PPHx and new psychiatric symptoms... Agree with checking endocrinologist

 

[ObsequiousAplomb]

Disclaimer - still a resident
I'm curious if lamictal has been stopped or maybe held the day of ECT? I am wondering how this might theoretically affect the treatment of her depression and how the ECT specialist is handling this.
I think Splik's remark about possibility of neurocognitive disorder is interesting, as the patient is elderly and bipolar patients are at higher risk for developing dementia.
I found it really interesting how Splik mentioned that the usual antipsychotics for bipolar depression (e.g. lurasidone, quetiapine, cariprazine) would not be very useful for psychotic form of bipolar depression. I have never heard that before.
Also never heard anything about ssri/snri's or TCA's being helpful for bipolar disorder. In my experience, bipolar patients do not benefit from antidepressants and I didn't think there was any evidence they do?
Albeit based on very limited experience, I think clozapine is a promising idea if ECT fails

I see people suggesting things like holding an anticonvulsant the day before ECT and I always wonder how exactly they think anticonvulsants and tissue/serum levels work. Lamictal's half-life is more than 24 hours. I imagine that since the serum level wouldn't change appreciably that the tissue level wouldn't change at all.

I can't imagine there's any benefit at all to holding any anticonvulsants the day of ECT. I've never seen any evidence that it is beneficial, despite seeing people hold Depakote ER the day of ECT for years due to some hypothetical benefit.

 

[Psych Person]

Thanks! Yes, by beautifully, it used to only take 3 sessions at most to see a notable difference. So this is definitely different for her. Past courses needed no more than 7 sessions before we found the plateau which was usually full remission. It's odd, once after 2 sessions of ECT she went manic. Another time when she was catatonic, we did the lorazepam thing which broke it very effectively...and she went manic with the pressured speech, increase in goal directed activity (husband left her to wait in the car one day and told her to stay put and by time he was back found her in a grocery store with a full cart rambling about a vacation home that doesn't exist), not sleeping, grandiose, definitely lost touch with reality. She's in her usual depressed state now--somatically preoccupied about being dehydrated and not eating enough. At night husband struggles but manages to get her to take meds because she fears they will kill her by the following morning, this is every time she's depressed.

Definitely wish husband would be more aggressive with the light therapy. Nothing to lose by it. But he's skeptical and does not follow through. But yet he's apprehensive of ECT too. He usually does not take her in until he's at his wits end. That or, last year I refused to see them for a follow up until they've contacted the ECT clinic and started ECT again (if the MD recommends it of course). She was so catatonic that I expressed concern of her being a DVT risk and I had a set a boundary. I've known her now for about 6 years. He keeps bugging me (yes, it's my counter transferance) to "just try another med, maybe it will perk her up". I've tried every mood stabilizer too. I've even at one point tried an MAOI (nardil--but maybe I should try another? as @clausewitz2 said, we're past the algorithm). Tried loxapine as well. No MAOI with ritalin though. Now with this round of ECT, he said for the time being he's giving up on ECT and tried to schedule another appointment with me "maybe a med change will perk her up." I responded that, med changes never have (at least under my care) and I suspect, very possibly, they never will. It just sounds so stupid--the family and I go through this every year. "not ECT yet, just try another med, just please keep trying meds if this next one doesn't work." So I coordinated with the ECT psychiatrist and got the pt and husband to follow up with him to discuss treatment planning next week, I'll be in the call via audio as well. It sounded like she may have had more of the cognitive side effects (the psychiatrist thinks this patient actually was starting to show response--husband's narrative though saw no benefit) and the ECT psychiatrist and I are thinking of continuing ECT but with more time between sessions and talking some more about the ECT technique used. He enjoys seeing this patient too and has used this case to teach medical students what bipolar I and using ECT looks like. It sounded like a combination of some more ECT side effects but also partly that husband still does not want to keep pursuing ECT and is hoping for the med route. But I'm like, totally out of meds. At least the most promising ones!

I agree, it's easier to bring someone down than up, lol! I have wondered about TMS for maintenance but there's no insurance reimbursement for that. But that angle would be very very interesting. I also agree that psychotherapy has nothing to lose and I'm not opposed. It's just hard to make progress because she keeps going back to talking about dehydration and not enough food. Then spouse chimes in with "are we gonna make a med change today?" lol

The case, which you have described in good detail, gives me the sense that there is a lot more going on in this patient’s life and history than any of us, and even you, might be aware of. The case seems off—it smells funny.

Are you absolutely sure that she is actually taking all of her medication, that there is no substance abuse, and that her labs and physical exam are unremarkable?

And why no adjunctive antipsychotic like Vraylar, Rexulti, Latuda, Geodon, Abilify, Seroquel, Abilify, Saphris, Risperdal? A regimen of Lithium, Lamictal, and an Antipsychotic would be fine if it led to stability.

It sounds like there is psychosocial chaos. There are sooo many variables in effect here, some I can potentially imagine and I’m sure many more that I can’t begin to think of and probably would be surprised to learn about. This case sounds challenging from a purely psychiatric perspective—then add all the dysfunction and inconsistency surrounding it, and this is a nightmare that would lead to many psychiatrists feeling frustrated and helpless if they didn’t realize there was MUCH more than meets the eye.

Lastly, of course, consider all the complex potential medical explanations, as you have, but don’t go to these lower probability extremes as a reaction to feeling stressed by the situation in large part due to the psychosocial disarray of the patient’s life (if there is the possibility this is happening for you). Also, don’t deny the patient’s own role and responsibility after all of these years in creating this chaotic situation that she is currently in. Hold them all responsible for their own lives. It’s not your responsibility to fix their mess—only to treat any apparent illness and to make recommendations and referrals for those things that are not in your scope or skillset. Continue to set those firm boundaries, don’t try to rescue them, and try new things (like medication regimen adjustments) and continuing ECT while optimizing as needed. Stay on your toes with this one, remain skeptical, be thorough, do what you are required to do (safety, ethics, standard of care, etc) but don’t get so lost in this case that you can’t think clearly. I’m not assuming that you are definitely experiencing any of this, just imagining what one might experience in a similar situation to yours based on what you shared.

You seem wholly dedicated and caring. Your patients are fortunate to have you.

 

[Candidate2017]

I will of course keep trying. Am of course doing my own work to not take it too hard.

I don't if there is or is not something else in your particular example.

But philosophically, I wonder why psychiatrists don't handle treatment failure very well. Why do we always believe there is something more we can do and ask, "What next?"

Imagine if vascular surgeons, oncologists, or neurologists thought like psychiatrists. They'd repeatedly amputate noncompliant diabetics until there's nothing left, decline to discuss hospice in favor of a 50th round of chemo, or keep brain dead patients on life support indefinitely until they die of infection.

 

[clausewitz2]

Imagine if vascular surgeons, oncologists, or neurologists thought like psychiatrists. They'd repeatedly amputate noncompliant diabetics until there's nothing left, decline to discuss hospice in favor of a 50th round of chemo...

I mean, vascular surgeons and oncologists sometimes actually do behave this way.

 

[calvnandhobbs68]

Imagine if vascular surgeons, oncologists, or neurologists thought like psychiatrists. They'd repeatedly amputate noncompliant diabetics until there's nothing left, decline to discuss hospice in favor of a 50th round of chemo, or keep brain dead patients on life support indefinitely until they die of infection.

I mean there's a difference between aggressively going after treatment failure and keeping brain dead patients on life support. Quite a large difference.

And yeah as mentioned above, walk into any MICU/SICU in the country and you'll find plenty of ethically questionable stuff going on in terms of aggressive treatment of geriatric patients (like why did the 96yo with multiple comorbidities need to go to the OR for a hip replacement again?)