PSYCHOGERIATRICS 2014; 14: 269–270
LETTER TO THE EDITOR
Transcranial direct current stimulation for depression in a 92-year-old patient: a case study Pedro SHIOZAWA,1 Mailu Enokibara da SILVA,1 Danielle Rigueira DIAS,1 Ana C CHAVES,2 Breno Satler de OLIVEIRA DINIZ2 and Quirino CORDEIRO1
The Clinical Neuromodulation Laboratory, Department of Psychiatry, Santa Casa Medical School, São Paulo, and 2Department of Psychiatry, Federal University of Minas Gerais, Belo Horizonte, Brazil
Dear Editor, The prevalence of clinically significant depressive syndromes in people 60 years and older (i.e. late-life depression (LLD)) ranges from 9% to 18%, with incidence rates of 19.3 per 1000 person years.1,2 LLD has been linked to increased rates of suicide and premature mortality and more frequent use of health care with significantly higher health-care costs.3 There is considerable heterogeneity in the clinical presentation of major depression across the life cycle. Younger patients may have clinical profiles characterized by high trait anxiety and variable patterns of circadian, sleep, energy, and appetite disturbance.4 Those in midlife present the more stereotypic picture of anhedonia in combination with sleep disturbance, weight loss, and cognitive and motor impairments. In later life, clinical phenotypes are again more variable.5 This may well reflect different neuropathological pathways to illness and largely differentiate those with earlier onset who have grown older from those experiencing clinical depression for the first time. The prognosis of LLD is typically poor and is characterized by chronicity, mortality, and increased risk for cognitive impairment and progression to dementia.6 We aim to evaluate the clinical effects of using a transcranial direct current stimulation (tDCS) protocol – a non-invasive therapeutic strategy in terms of safety and clinical impact – on depressive symptoms. The rationale for using tDCS for depression is based on its properties of increasing (anodal) and decreasing (cathodal) cortical excitability. A larger study on depression and tDCS was recently published by © 2014 The Authors Psychogeriatrics © 2014 Japanese Psychogeriatric Society
Brunoni et al.7 The authors performed a controlled trial involving 120 patients with major depression. The results of this factorial study, in which subjects were randomized to receive active or sham tDCS and verum or placebo sertraline, showed a significant improvement in depressive symptoms for tDCS alone or combined with sertraline. Favourable results have also been found by other groups studying major depressive disorder.8 To the best of our knowledge, this has not yet been evaluated specifically for the old-old population. Mr J is a 92-year-old patient who has had major depression for the last 3 years. The patient presented no significant changes in complementary tests. Neuroimaging evaluation (magnetic resonance imaging) showed no volumetric or structural modifications other than age-related changes. At presentation, the patient was using escitalopram 10 mg/day without clinical response. Given the availability of tDCS device in our centre, it was decided the patient should undergo a tDCS protocol for major depression. The patient provided written informed consent in accordance with the requirements of Santa Casa Medical School’s institutional review board. Intervention protocol was as follows: 10 sessions with 2 mA for 30 min (only on weekdays). The anode was placed over the left dorsolateral prefrontal cortex (F3 according to the 10/20 electroencephalogram system) and the cathode was placed extracephalic at the contralateral deltoid. Depressive symptoms were assessed using the 17-item Hamilton Depression Rating Scale; we evaluated anxiety symptoms with 269
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the Beck Anxiety Inventory and cognitive function with the Montreal Cognitive Assessment Scale. After 10 sessions, the patient presented with satisfactory clinical response. The Hamilton Depression Rating Scale score decreased by 17 points (94.4%) from baseline, and the decrease was maintained during the 3-week follow-up. Exploratory analysis showed no significant changes for anxiety as assessed by the Beck Anxiety Inventory (decrease from baseline, 16%; from 6 to 5 points) or cognitive symptoms as assessed by Montreal Cognitive Assessment Scale (increase from baseline, 3.8%; from 26 to 27 points). The intervention was well tolerated and no adverse effects were reported. How the age of depression onset affects prognosis and treatment response is uncertain. Age may have a complex relationship with depression; it is highly correlated with a number of other known risk factors that affect prognosis. Elderly depressed patients with an early first onset of depression are more likely to have a greater number of relapses in their lifetimes and an overall longer duration of illness; both of these factors are important predictors of poor prognosis. Alternatively, patients presenting with depression for the first time in later life have an increased risk of physical comorbidities, and physical comorbidity has been associated with a poorer prognosis.9 While there have been many studies investigating response to pharmacological treatments in middle-aged persons, there have been remarkably few studies specifically focused on assessing interventions in older persons, particularly those with LLD. A recent large-scale, general practice-based review of treatment of depression in older persons indicated the extent to which the widespread prescribing of selective serotonin re-uptake inhibitors is associated with important side-effects (e.g. falls, hyponatraemia, agitation);10 it also indicated the extent to which some classes of selective serotonin re-uptake inhibitors may be associated with more significant risks, including increased risk to stroke, seizures, fracture and premature death. Compared to middle-aged patients, older
persons may take longer to respond to antidepressant medication, and unfortunately, as many as 50% of patients with LLD will not achieve remission with the first treatment,11 warranting the need to consider alternative non-pharmacological options in some subgroups. Evaluating the clinical effects of tDCS protocols on depressive symptoms is fundamental to our understanding of the precise clinical uses of this new technology among specific populations.
REFERENCES 1 Luijendijk HJ, van den Berg JF, Dekker MJ et al. Incidence and recurrence of late-life depression. Arch Gen Psychiatry 2008; 65: 1394–1401. doi: 10.1001/archpsyc.65.12.1394. 2 Beekman AT, de Beurs E, van Balkom AJ, Deeg DJ, van Dyck R, van Tilburg W. Anxiety and depression in later life: co-occurrence and communality of risk factors. Am J Psychiatry 2000; 157: 89–95. 3 Katon WJ, Lin E, Russo J, Unutzer J. Increased medical costs of a population-based sample of depressed elderly patients. Arch Gen Psychiatry 2003; 60: 897–903. 4 Hansell NK, Wright MJ, Medland SE et al. Genetic co-morbidity between neuroticism, anxiety/depression and somatic distress in a population sample of adolescent and young adult twins. Psychol Med 2012; 42: 1249–1260. 5 Blazer DG. Depression in late life: review and commentary. J Gerontol A Biol Sci Med Sci 2003; 58: 249–265. Review. 6 Djernes JK, Gulmann NC, Foldager L, Olesen F, Munk-Jørgensen P. 13 year follow up of morbidity, mortality and use of health services among elderly depressed patients and general elderly populations. Aust N Z J Psychiatry 2011; 45: 654–662. 7 Brunoni AR, Valiengo L, Baccaro A et al. The sertraline vs. electrical current therapy for treating depression clinical study: results from a factorial, randomized, controlled trial. JAMA Psychiatry 2013; 70: 383–391. 8 Shiozawa P, Fregni F, Benseñor IM et al. Transcranial direct current stimulation for major depression: an updated systematic review and meta-analysis. Int J Neuropsychopharmacol 2014; 17: 1443–1452. 9 Subramaniam H, Mitchell AJ. The prognosis of depression in late life versus mid-life: implications for the treatment of older adults. Int Psychogeriatr 2005; 17: 533–537. 10 Coupland C, Morriss R, Arthur A, Moore M, Hill T, Hippisley-Cox J. Safety of antidepressants in adults aged under 65: protocol for a cohort study using a large primary care database. BMC Psychiatry 2013; 13: 135. 11 Roose SP, Schatzberg AF. The efficacy of antidepressants in the treatment of late-life depression. J Clin Psychopharmacol 2005; 25 (4 Suppl 1): S1–S7.
© 2014 The Authors Psychogeriatrics © 2014 Japanese Psychogeriatric Society
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