ECT
FOR
CHRONIC
PAIN
pnession, homosexuality, or marital maladjustment. These physicians seem to equate “different” with “sick,” and no doubt serious injustices in the form of insensitive treatment, forced confinement, and the nefarious “labeling” have occurred. Nevertheless, and this is especially true in many state-operated and community facilities today, it is as if mental illness, as illness, does not exist, and use of medical therapies such as ECT is disparaged and simply not available to patients. Diagnosis is deemed irrelevant just at a time when logic dictates that it is more important than it has ever been. From the point of view of the layman, who comprises the majority of patients, the schism that I have described can only appear as further evidence that psychiatrists have little to contribute to the well-being of society. The pernicious consequences of one’s choice of treatment were highlighted several years ago when a high government official was denied a chance for even higher office by virtue of the treatment he had accepted for an alleged depressive episode. Because he had received ECT, his fitness for high office was suddenly in question. Had he had the same symptoms but been treated with psychotherapy, plus or minus medication, his chances might have been different. Unfortunately, too many psychia-
Electroconvulsive BY
MICHEL
R.
Therapy MANDEL,
for Chronic
THE MOST DIFFICULT patients to treat in medical practice are those who present with pain problems requiring a subtle differentiation between predominantly physiologic pain and psychogenic pain. The histories of these patients often read like odysseys, with multiple hospitalizations, clinical procedures, and physician contact. Engel (I) has described this group of patients as “pain prone.” Frequently they are not psychologically oriented people, in fact, just the opposite, and they often reject attempts to obtain psychiatric consultation. It has been AMONG
AmJ
Psychiatry
COMMENT
In this presentation of the history of my father’s mental illness and my family’s attempts to get treatment, an effort has been made to highlight the consequences of the obvious lack of communication among various schools of psychiatry. It has not been my intention to denigrate anyone’s approach but rather to point out that we have much to learn from one another in dealing with the problems our patients present to us.
Associated
with
Depression
M.D.
Electroconvulsive therapy alleviated the symptoms of f our out ofsix patients sufferingfrom chronic pain and f rom depression as measured by the Hamilton Depression Rating Scale. All ofthe patients had been unsuccessfully treated with tricyclic antidepressant medication. The author suggests that ECT may be the treatment ofchoiceforsomepatients with this combination of symptoms.
632
Pain
tnists trained to believe that ECT has few indications and then only for the “very ill” are unable or unwilling to properly inform a public which still looks upon ECT as a form of electrical purgatory or last-ditch radical treatment for the virtually hopeless. In my own training I can vividly recall looking for an appropriate candidate for ECT only to have every candidate rejected as “not that ill.” I am certain that had my father been admitted to my residency training program, he would not have been considered ill enough to receive ECT. Even if he had been so considered, the issue would never have been raised out of deference to me.
132:6,June
1975
shown that the presentation of the painful symptom is influenced by the patient’s individual personality and other variables, including cultural background, suggestability, and various types of stress (2). Theme is often a strong suggestion that this group of patients has long-term psychological difficulties (3). Various contributing factors maintain the symptom complex in chronic pain syndrome, including malingering, hypochondriasis, and conversion reaction (I, 4, 5). Several authors have shown that depression can also play an important role in pain and that affective disorders sometimes accompany other diagnoses such as conversion reaction ( 1 4). Ziegler and associates (6) reviewed the cases of 100 randomly chosen patients with a ,
Dr. Mandel is Assistant in Psychiatry, tal, Fruit St., Boston, Mass. 02114, and chiatry, Harvard Medical School. The author wishes to thank Alan ett, M.D., and Gerald 1. Klerman, the preparation of this paper.
Massachusetts Instructor,
General Department
Hospiof Psy-
J. Gelenberg, M.D., Thomas P. HackM.D., for their valuable assistance in
MICULI.
primary diagnosis of depression onstrated conversion symptoms this group was 46.5 years.
and found that 28 demof pain. The mean age of
TREATMENT
4
The presence of affective symptoms is often a good prognostic sign in psychiatric illness, especially ifthey are acute, and it would seem reasonable to attempt to separate out a depressed subgroup of chronic-pain patients for antidepressant therapy. This is particularly true since with the introduction of electroconvulsive therapy in the l940s and monoamine oxidase inhibitors and tricyclic antidepressants in the middle 1950s, many depressions have been rendered treatable (7). Various investigators, particularly in the British literatune, have described their varying success in treating chronic-pain patients with mood-altering drugs such as antidepressants, phenothiazines, and antihistamines (4, 8). In general, it has not been possible to precisely identify this group on the basis of psychological factors such as depression. It is not known what percentage of depressed chronic-pain patients respond to antidepressants, but I have found that many of them do not experience symptorn relief with this therapy. ECT has had varying degrees of success in the treatment ofpatients with chronic pain (9-I 1). A MEDLARS (Medical Literature Analysis and Retrieval System) computer search of the world literature for the past 20 years revealed only a few articles relating to the efficacy of ECT in this group of patients (9-12). In one of the most recent reports, which was published in 1957, Von Hagen (10) reported on 8 patients with intractable pain and extensive histories of pain. All of his patients did well, and although their psychiatric histories were not extensive, depression was mentioned in 6 of them. Weinstein and associates (I I) selected 10 patients with longstanding pain from the neurological ward of a general hospital and found that there was no essential change in their perception ofpain beyond the period ofdelinium induced by bilateral ECT. These researchers concluded that ECT was not a feasible method for the relief of intractable pain. They did not mention whether these patients also suffered from depression. Bradley (12) has suggested that the coincident onset of pain and depression is associated with the relief of pain when the depression is treated with ECT. This paper reports on a study of 6 patients with chronic pain who had failed to respond to tnicyclic antidepressant therapy. These patients were considered clinically depressed and received a series of ECT in the course of their clinical cane.
THE
PATIENT
SAMPLE
Hamilton Depression Rating for a group of chronic-pain General Hospital who were
DEL.
judged to be clinically depressed and were undergoing clinical evaluation for further treatment. Six patients with scores higher than 20 -indicating at least moderate depression-were selected for the study. The patients consisted of I man and S women, ranging in age from 47 to 73 (median age=54.5 years). All had undergone extensive neurological and medical diagnostic procedures, and a significant physiological basis for their pain had been eliminated. The duration of pain varied from 6 months to 30 years. In five of the six cases, the pain became more intense and was associated with depressive symptoms over a 6- to 24-month period prior to consultation. In most of the patients, significant psychological themes of secondary gain could be identified, and theme were often conflicts within their nuclear families vis-#{224}-vissuch issues as dependency and aggression. Five of the 6 patients could not be considered psychotic unless the pain symptoms themselves could be called delusional. One patient (case 3) was eventually diagnosed as psychotically depressed. The pains included backache, atypical facial pain, headache, and chest pain. All of the patients could be considered addicted to various narcotics at some time during their treatment for pain; 4 were addicted at the time of consultation. All of the patients had been treated with tnicyclic antidepressants; this therapy was unsuccessful despite the fact that adequate amounts of drugs had been prescribed (dosage trials were the equivalent of 200 to 250 mg of imipramine daily). Three patients denied feeling depressed, and the 3 who did identified depression as a secondary symptom. None of the patients could be considered manic-depressive or suffering from primary affective disorder. All of them met the criteria for secondary affective disorder established by Feighner, Robins, and associates (14). The patients received nondominant hemispheric unilateral ECT 3 times per week. The procedure was modified by atropine, methohexital, and succinylcholine anesthesia. Four patients demonstrated a remarkable improvement in pain and depression. Clinical data on the sample are presented in table I.
CASE
REPORTS
Responders Case 1. A 47-year-old contractor headaches in the left temporal area as if”someone
had
in
of
the
context
son’s
subsequent
riage,
with
quartered the
birth
son
and
of
an
experienced
The
illegitimate
and
rapid
grandchild
pain
first
and of
the
coming
times
withdrawal of
ternist
treated
tablets
daily
occurred
unavoidable him
intermittently
argument with
with
various
of a semisynthetic
who blamed
felt
occurred
grandson
annulment
eventually
The patient,
intense
he said they
to
his mar-
live
in
for his family’s misfortune, did not feel that he could protest or complain about his son because of his own history of severe alcoholism, which had persisted until hejoined Alcoholics Anonymous 10 years prior to his admission. The patient’s headache and his at
household.
had
for 5 years:
my head.”
marriage
the
the patient’s
emotional
Index scores on the Scale (13) were obtained patients at Massachusetts
R. SIAN
his
analgesics,
narcotic
AmJPsychiatryl32.6,June
himself
and son
particularly
and wife. His inincluding
analgesic
1975
up
to
(Percodan)
633
8
ECT
FOR
CHRONIC
TABLE
PAIN
I
Clinical
Characteristics
ofSix
Patients
with
Chronic
Pain
and
Depression
Sex
Age
I 2
M F
Married Married
47 55
Head Head
5 years 20 years
3
F
Single
64
Chest
IOmonths
Patient
Comfortable
.
.
Duration
Location of Pain
Marital Status
of Pain
Overall
.
Hamil
During
Acute
Observation
ton
Score
Subjectively Depressed
Personality Diagnosis
Pre-ECT
Post-ECT
40 26
3 14
Yes No
Passive-dependent, Passive-dependent,
59
5
Yes
Mixed, with passive-aggressive and hysterical elements. moderate severe Hysterical personality. moderate
Responders
4
F
52
Married
Back. face, head,
0 2 years
No Intermittently so No
l0months
6 months
6 months
No
53
II
Yes
mild mild
to
chest Nonresponders 5 6
F
Married
73
Face
20 years
2 years
Intermittently so
32
19
No
F
Married
68
Face, head
30 years
2 years
Yes
25
22
No
Hysterical personality. moderate to severe Passive-aggressive dcments, moderate to severe
and antidepressant medication. He was hospitalized because of addiction to the analgesic and decreasing work performance. Mental status examination revealed a depressed man with sad facies, stooped posture, and slow speech. He constantly meferred to his headaches and appealed to the examiner for some medication. He admitted to symptoms of depression only during specific questioning. He scored 40 on the Hamilton depres-
the
around, her husband reported and she reported no recurrence
that she was strikingly of pain.
sion scale.
Case 3. A 64-year-old single on a psychiatric unit to which
she had been
medical
been
Following a series of 6 unilateral ECTs, the patient’s ache disappeared and his Hamilton score fell to essentially On 2 occasions in the year of follow-up he has become jectively
depressed
and
has
been
given
a 6-week
mg of doxepin at bedtime. He has not missed since his discharge from the hospital, and his not recurred. Case 2. A 55-year-old salesman
graine” tartrate
analgesic mines
not
only
(Cafergot) She stated
and
to reduce
her
her
pain
hospitalization
but
was
move to a new location about home, as well as by the Food stringent
control
a day headaches
have
to “get
narcotic ampheta-
me going,”
and
20 years. She had 2 years prior to ad-
triggered
in part
by her
200 miles away from her previous and Drug Administration’s more
of amphetamines,
which
made
it difficult
for
her to obtain them. Her internist, noting that she appeared depressed, treated her with up to 250 mg of amitniptyline, at bedtime, for several months prior to ECT; there was no change in her symptomatology. During her mental status examination she was extremely reluctant to talk to the examiner and insisted that the lights be turned
off
during
the
interview
because
they
exacerbated
her
“migraine.” When she did talk, she spoke of missing her previous home and her “pep pills,” and she complained that her husband was away much of the time-yet denied being the type who would complain. Despite an elevated Hamilton score of 26,
634
A m J Psychiatry
132:6, June 1975
denied
being
depressed
her depression once her mood brightened
6-month
follow-up
ward,
where
pain.
Initially
closer
questioning
she
and ready previous
her
she
seemed
to fall out.
score
quite
Her
“rotten”
and
6 unilateral very
that
pleasant
capable,
ensuing
with
from
severe
a
chest but
was
“split
on
in two”
was 59. There depression.
oftime
was no Mood-
to treat
her.
After
metamorphosis
quite
situation.
mother
in consultation
score
free and had a Hamilton
A 52-year-old
up and
improved,
transferred
somewhat
living
Case 4. of her life 6 months set of pain pain over
was
ofsevene
although
able to cope
was symptom
seen
heart
a surprising
pending
in her
to talk
without any success. When she replied that her brain was
who was subsequently change
able
psychologically,
her
be a waste
she had
and
was
intact
that history
it would
ECTs
only
14, she
admitted
Hamilton
or family
was
woman
had
was
had begun. After 6 unilateral hen headache disappeared. At
Hamilton
she claimed
personal
and
ECT and
elevating drugs were prescribed, ECT was suggested to the patient,
and a semisynthetic that she also needed
she had used them intermittently for almost lived near her family for her entire life until mission,
sub150 of work of
married mother of two and wife of a intermittently for 20 years of “miwas relieved somewhat by ergotamine
complained headache, which had
and caffeine (Percodan).
course
headzero.
patient
about ECTs
into
lonely,
effectively
with
1-year
follow-up
At
score
of five had
a
woman,
an imshe
of 5. been
well
for
most
with the exception of a hysterectomy at age 42. About prior to seeing her physician, she experienced the onin her upper night cheek with occasional “shooting the top of my head and down my spine.” During the
several
months
her
appetite
diminished,
she
lost
ap-
proximately 15 pounds, and her interest in her everyday household chores diminished to the point where she was spending her days in bed. She complained to her physician of poor appetite and loss of interest in food, occasional palpitations, shortness of breath, and a “full, uncomfortable feeling” in the upper left side of her chest. Her physician noted that she appeared sad, and when he asked her specifically if she was depressed, she admitted that she was but added emphatically that it was due to her severe pain and that her problems were certainly physical. After an extensive work-up her physician prescribed a regimen of
MICHEL
imipramine,
tenly
but
it
ofdizziness
After
was
and
the
discontinued
dry
patient
after
she
bit-
complained
had
FIGURE
I
Pretreatment
mouth.
undergone
many
complete
R. MANDEL
Mean
Scores
on Individual
Hamilton
Scale
Items’
examResponders
inations by various specialists and continued to complain of severe pain, her physician arranged for an interview with her and her husband. Her husband reported many bizarre symptoms and increased suspiciousness. He also said that the patient had talked about being punished, about having a brain tumor, and had spoken ofdeath on several occasions. It became somewhat
E:J
Nonresponders
a
>
C >, U C
0 0
E a)
more clear at this point vere and even delusional
that her pain might be a screen for a seaffective illness, and a psychiatric consultation was arranged. The patient’s Hamilton score was 53. The patient received a total of 10 unilateral ECTs, with initial brightening of mood and disappearance of vegetative signs and
4r-
r
;g .?
:
a)
C
c
:
a
;
(3
n
E
n
D
5
2
symptoms. Her pain persisted until the seventh ECT and then disappeared. At 6-month follow-up the patient was essentially back to her former normal self and was asymptomatic. Her
husband
reported
that
she
occasionally
numbness in the areas previously complaints were transient. Her low-up was I I.
complained
described Hamilton
of mild
as painful, but score at 6-month
these fol-
4
73-year-old wife of a dentist developed maxillary facial pain 20 years prior to psychiatric consultation, after her discovery of her husband’s brief affair some years earlier. After consulting various physicians at that time, she was able to “tolerate” the pain, which was relieved by intermittent use of carbamazepine (Tegretol). Shortly after her husband’s semiretirement 2 years prior to psychiatric consultation, her pain worsened and she withdrew to her bed, with his almost constant ministering to her. One year prior to her admission, she was admitted to a psychiatric hospital under somewhat vague cincumstances and received 12 ECTs with quite striking improvement. a neurosurgical medication
prior
to her referral
evaluation, administened,
was
to another
hen pain slowly but multiple
hospital
.
“like
returned. Tricyclic side effects devel-
She suffered from marked constipation and appetite. Her Hamilton score was 32. After her Hamilton score fell to 15, and her pain but did not disappear. Shortly after her began to complain of pain once again. At
a slap.”
and 7 unilateral ECTs decreased somewhat arrival home she loss
of
weight
6-month follow-up her condition was essentially from what it had been originally; her Hamilton score 6. A 68-year-old
bank and pain in the right
(‘use
headaches neurosurgical
consultation
local
physician
was
19.
after
of for
unsuc-
cessful treatment with many therapies, including acupuncture and tric’yclic antidepressants. Her pain had intensified over the past 2 years since the retirement of her husband and their close involvement in an antique business. Her medical history revealed that she had cared for hen ailing mother until the latter’s death and that at age 35 she had married the vice-president of the bank in which she worked. Since her husband’s retirement she
had
spent
and much
much
of their
lief for her pain.
She
appeared
was begun antidepressant
condition
of her
The
changed
in bed,
focused
with
him
on searching
caring
for her,
for new re-
patient’s
depressed
on a course therapy.
had
time
life together
1-lamilton score was 25. on mental status examination and of ECT after an unsuccessful trial on After 9 unilateral ECTs the patient’s
little;
she returned
home
.c
0
0 0
a E
C 0
a
c
>
nI
,
-
oa
0
.C n
C
no
n
E
,
a. E
n N
-
‘
C 0
a
C
a)
I1l
HI
0
.E
14
15
16
HAMILTON *Higher
scores
the same further
I)ISC
indicate
increased
situation,
the referring time
in bed.
17
SCALE
psychiatric
At 5-month
19
0
20
21
ITEMS
or medical
follow-up
and had remained Her
18
a
pathology.
refusing
hospital.
consultation
of her
o
JiLWLLLL
012J
‘
(0
Hamilton
at home,
score
follow-up
she had
at that
spending time
at
not sought was
most 22.
U.SSION
unchanged
teller with a 30-year history side of her face was referred
by her
E +-
for
oped, prohibiting its further use. On examination, her behavior was coquettish and mildly inappropriate, with intermittent sadness, but there was no cvidence of dementia. She repeatedly referred to her pain as burning
0 C 0
,
Case 5. The
the 12 months
C 0
,
Nonresponders
Over
10
-
to essentially
Figure 1 presents the responders’ and nonresponders’ mean scores on individual Hamilton items. This is an uncontrolled study, and conclusions must be tentative. However, the Hamilton scores suggest that ECT may alleviate both the pain and depression ofdepressed, chronic-pain patients who present with guilt, psychomotor retardation,
suicidal
ideation,
increased
agitation,
anxiety,
depersonalization, and paranoia. It is also ofinterest that the two nonresponders were the oldest in the group and had suffered from pain for 20 years or more. The cases presented highlight the problem of potentially undertmeated depressions with somatic symptoms, in both medical and surgical settings. Our experience with these patients confirms Bradley’s suggestion (12) that the onset of pain coincident with depression is melated to relief of both with ECT and Ziegler and associates’ impression (6) that conversion symptoms includAmJ
Psychiatry
132.6,June
1975
635
PROFESSIONALS
WORKING
OVERSEAS
ing pain in patients over the age of 40 may be related to depression. These cases are also presented to demonstrate that the application of an easily administered depression rating scale may be useful in documenting depressive illness in this group. It should be stressed that these selected patients with high Hamilton depression scores were followed closely, with attention to psychosocial set, and provisions for adequate follow-up and family support were made in each case. Difficulties may loom ahead for an uncritical application of ECT without attention to these matters. These patients represent one subgroup of a chronicpain population presently under study, and this report is intended to alert physicians to the possible use of ECT in depressed patients presenting with pain syndromes. It appears from these cases that ECT may alleviate the symptoms of depression and pain in a significant number of patients who have been unsuccessfully treated with antidepressant medication.
2.
Mechanic of bodily
D: Social
psychologic
factors
affecting
tions: 7. 8. 9.
a clinical
shock 10.
study.
Am J Psychiatry
Klerman GL: Research 24:305-319, 1971 Merskey H, Hester RA: chotropic drugs. Postgrad Pisetsky JE: Disappearance Von
treatment. Hagen
KO:
and
report
nism
165:773-777,
1 1. Weinstein therapy
in
1 16:901-909,
depression.
Arch
The
Engel GL: 26:899-918,
Psychogenic 1959
Depressive
Working B
LUCY
pain
and
the
pain-prone
Syndrome:
patient.
Am
J Med
A Follow-Up
Psychiatry
of eight
cases
treated
with electroshock.
JAMA
1957
EA, Kahn RI, Bergman PS: Effect of electroconvulsive on intractable pain. Arch Neurol Psychiatry 81:37-42,
23:56-62,
with
the
J Neurol
depressive Neurosurg
1960
14. Feighner JP, Robins E, Guze SB, et at: Diagnostic criteria for use in psychiatric research. Arch Gen Psychiatry 26:57-63, 1972
Study
of 130 Professionals
Overseas JANE
KING,
MI).
A four-yearfollow-up ofprofessionalpersonnel who had been working overseas indicates that the depressive syndrome was the most common diagnosable psychiatric illness in this population. The study also shows that in this context the syndrome had a goodprognosis. It therefore seems reasonable not to exclude persons with diagnosable depression from assignment abroad but, rather, to identtfy the syndrome and recommend necessary treatment.
INTERVIEWS HAVE BEEN CONDUCTED with 130 professional personnel from the United States working in 12 countries in Asia, Africa, or Latin America before and after their terms of service overseas, which lasted from two to six years (mean, four years). This has made possible a follow-up study of psychiatric symptoms in persons who were chosen for work overseas because they
636
1960 Gen
The treatment of chronic pain with psyMed J 48:594-598, 1972 of painful phantom limbs after electric Am J Psychiatry 102:599-601, 1946 Chronic intolerable pain-discussion ofits mecha-
1959 Bradley ii: Severe localized pain associated syndrome. Br J Psychiatry 109:741 --745, 1963 13. Hamilton M: A rating scale for depression.
Psychiatry I.
presentation
112:651-659, 1966 5. Davis D, Weiss MA: Malingering and asSociated syndromes, in American Handbook of Psychiatry, revised 2nd ed, vol 3. Edited by Arieti S. New York, Basic Books, 1974, pp 270-287 6. Ziegler FJ, Imboden JB, Meyer E: Contemporary conversion reac-
12. REFERENCES
the
complaints. N Engl J Med 286: 1 132-1 139, 1972 3. Lipsitt DR: Medical and psychologic characteristics of “crocks.” Psychiatry Med 1:15-25, 1970 4. Lascelles RG: Atypical facial pain and depression. Br J Psychiatry
AmJ
Psychiatry
132:6,June
1975
were functioning well in professional moles and who were placed in an environment where they would face cultural shock (1). As stated previously in a report on the initial interviews of 104 candidates for service overseas (2), the most common psychiatric syndrome seen was depression. This brief report will focus on affective and other psychiatric syndromes, family history of psychiatric illness, and certain aspects of living and work situations abroad.
At the time this paper was written, Dr. King was Associate Professor, Department of Psychiatry, Washington University School of Medicine, St. louis, Mo. She is now Professor, Departments of Psychiatry and Pharmacology, Medical College of Virginia, Virginia Commonwealth
University,
Richmond,
partment
This Career Mental
Va. Address
of Psychiatry,
work
MCV
was supported
Development Health.
The author would like ton University Medical erature search.
Station,
in part by Award MH-l9394 to thank Library,
reprint
requests
Richmond,
to her at the DcVa.
23298.
grant MH-13002 and from the National
Ms. Margaret S. Cummings, St. louis, Mo., for assistance
Research
Institute
of
Washingin the lit-
FOR
CHRONIC
PAIN
pnession, homosexuality, or marital maladjustment. These physicians seem to equate “different” with “sick,” and no doubt serious injustices in the form of insensitive treatment, forced confinement, and the nefarious “labeling” have occurred. Nevertheless, and this is especially true in many state-operated and community facilities today, it is as if mental illness, as illness, does not exist, and use of medical therapies such as ECT is disparaged and simply not available to patients. Diagnosis is deemed irrelevant just at a time when logic dictates that it is more important than it has ever been. From the point of view of the layman, who comprises the majority of patients, the schism that I have described can only appear as further evidence that psychiatrists have little to contribute to the well-being of society. The pernicious consequences of one’s choice of treatment were highlighted several years ago when a high government official was denied a chance for even higher office by virtue of the treatment he had accepted for an alleged depressive episode. Because he had received ECT, his fitness for high office was suddenly in question. Had he had the same symptoms but been treated with psychotherapy, plus or minus medication, his chances might have been different. Unfortunately, too many psychia-
Electroconvulsive BY
MICHEL
R.
Therapy MANDEL,
for Chronic
THE MOST DIFFICULT patients to treat in medical practice are those who present with pain problems requiring a subtle differentiation between predominantly physiologic pain and psychogenic pain. The histories of these patients often read like odysseys, with multiple hospitalizations, clinical procedures, and physician contact. Engel (I) has described this group of patients as “pain prone.” Frequently they are not psychologically oriented people, in fact, just the opposite, and they often reject attempts to obtain psychiatric consultation. It has been AMONG
AmJ
Psychiatry
COMMENT
In this presentation of the history of my father’s mental illness and my family’s attempts to get treatment, an effort has been made to highlight the consequences of the obvious lack of communication among various schools of psychiatry. It has not been my intention to denigrate anyone’s approach but rather to point out that we have much to learn from one another in dealing with the problems our patients present to us.
Associated
with
Depression
M.D.
Electroconvulsive therapy alleviated the symptoms of f our out ofsix patients sufferingfrom chronic pain and f rom depression as measured by the Hamilton Depression Rating Scale. All ofthe patients had been unsuccessfully treated with tricyclic antidepressant medication. The author suggests that ECT may be the treatment ofchoiceforsomepatients with this combination of symptoms.
632
Pain
tnists trained to believe that ECT has few indications and then only for the “very ill” are unable or unwilling to properly inform a public which still looks upon ECT as a form of electrical purgatory or last-ditch radical treatment for the virtually hopeless. In my own training I can vividly recall looking for an appropriate candidate for ECT only to have every candidate rejected as “not that ill.” I am certain that had my father been admitted to my residency training program, he would not have been considered ill enough to receive ECT. Even if he had been so considered, the issue would never have been raised out of deference to me.
132:6,June
1975
shown that the presentation of the painful symptom is influenced by the patient’s individual personality and other variables, including cultural background, suggestability, and various types of stress (2). Theme is often a strong suggestion that this group of patients has long-term psychological difficulties (3). Various contributing factors maintain the symptom complex in chronic pain syndrome, including malingering, hypochondriasis, and conversion reaction (I, 4, 5). Several authors have shown that depression can also play an important role in pain and that affective disorders sometimes accompany other diagnoses such as conversion reaction ( 1 4). Ziegler and associates (6) reviewed the cases of 100 randomly chosen patients with a ,
Dr. Mandel is Assistant in Psychiatry, tal, Fruit St., Boston, Mass. 02114, and chiatry, Harvard Medical School. The author wishes to thank Alan ett, M.D., and Gerald 1. Klerman, the preparation of this paper.
Massachusetts Instructor,
General Department
Hospiof Psy-
J. Gelenberg, M.D., Thomas P. HackM.D., for their valuable assistance in
MICULI.
primary diagnosis of depression onstrated conversion symptoms this group was 46.5 years.
and found that 28 demof pain. The mean age of
TREATMENT
4
The presence of affective symptoms is often a good prognostic sign in psychiatric illness, especially ifthey are acute, and it would seem reasonable to attempt to separate out a depressed subgroup of chronic-pain patients for antidepressant therapy. This is particularly true since with the introduction of electroconvulsive therapy in the l940s and monoamine oxidase inhibitors and tricyclic antidepressants in the middle 1950s, many depressions have been rendered treatable (7). Various investigators, particularly in the British literatune, have described their varying success in treating chronic-pain patients with mood-altering drugs such as antidepressants, phenothiazines, and antihistamines (4, 8). In general, it has not been possible to precisely identify this group on the basis of psychological factors such as depression. It is not known what percentage of depressed chronic-pain patients respond to antidepressants, but I have found that many of them do not experience symptorn relief with this therapy. ECT has had varying degrees of success in the treatment ofpatients with chronic pain (9-I 1). A MEDLARS (Medical Literature Analysis and Retrieval System) computer search of the world literature for the past 20 years revealed only a few articles relating to the efficacy of ECT in this group of patients (9-12). In one of the most recent reports, which was published in 1957, Von Hagen (10) reported on 8 patients with intractable pain and extensive histories of pain. All of his patients did well, and although their psychiatric histories were not extensive, depression was mentioned in 6 of them. Weinstein and associates (I I) selected 10 patients with longstanding pain from the neurological ward of a general hospital and found that there was no essential change in their perception ofpain beyond the period ofdelinium induced by bilateral ECT. These researchers concluded that ECT was not a feasible method for the relief of intractable pain. They did not mention whether these patients also suffered from depression. Bradley (12) has suggested that the coincident onset of pain and depression is associated with the relief of pain when the depression is treated with ECT. This paper reports on a study of 6 patients with chronic pain who had failed to respond to tnicyclic antidepressant therapy. These patients were considered clinically depressed and received a series of ECT in the course of their clinical cane.
THE
PATIENT
SAMPLE
Hamilton Depression Rating for a group of chronic-pain General Hospital who were
DEL.
judged to be clinically depressed and were undergoing clinical evaluation for further treatment. Six patients with scores higher than 20 -indicating at least moderate depression-were selected for the study. The patients consisted of I man and S women, ranging in age from 47 to 73 (median age=54.5 years). All had undergone extensive neurological and medical diagnostic procedures, and a significant physiological basis for their pain had been eliminated. The duration of pain varied from 6 months to 30 years. In five of the six cases, the pain became more intense and was associated with depressive symptoms over a 6- to 24-month period prior to consultation. In most of the patients, significant psychological themes of secondary gain could be identified, and theme were often conflicts within their nuclear families vis-#{224}-vissuch issues as dependency and aggression. Five of the 6 patients could not be considered psychotic unless the pain symptoms themselves could be called delusional. One patient (case 3) was eventually diagnosed as psychotically depressed. The pains included backache, atypical facial pain, headache, and chest pain. All of the patients could be considered addicted to various narcotics at some time during their treatment for pain; 4 were addicted at the time of consultation. All of the patients had been treated with tnicyclic antidepressants; this therapy was unsuccessful despite the fact that adequate amounts of drugs had been prescribed (dosage trials were the equivalent of 200 to 250 mg of imipramine daily). Three patients denied feeling depressed, and the 3 who did identified depression as a secondary symptom. None of the patients could be considered manic-depressive or suffering from primary affective disorder. All of them met the criteria for secondary affective disorder established by Feighner, Robins, and associates (14). The patients received nondominant hemispheric unilateral ECT 3 times per week. The procedure was modified by atropine, methohexital, and succinylcholine anesthesia. Four patients demonstrated a remarkable improvement in pain and depression. Clinical data on the sample are presented in table I.
CASE
REPORTS
Responders Case 1. A 47-year-old contractor headaches in the left temporal area as if”someone
had
in
of
the
context
son’s
subsequent
riage,
with
quartered the
birth
son
and
of
an
experienced
The
illegitimate
and
rapid
grandchild
pain
first
and of
the
coming
times
withdrawal of
ternist
treated
tablets
daily
occurred
unavoidable him
intermittently
argument with
with
various
of a semisynthetic
who blamed
felt
occurred
grandson
annulment
eventually
The patient,
intense
he said they
to
his mar-
live
in
for his family’s misfortune, did not feel that he could protest or complain about his son because of his own history of severe alcoholism, which had persisted until hejoined Alcoholics Anonymous 10 years prior to his admission. The patient’s headache and his at
household.
had
for 5 years:
my head.”
marriage
the
the patient’s
emotional
Index scores on the Scale (13) were obtained patients at Massachusetts
R. SIAN
his
analgesics,
narcotic
AmJPsychiatryl32.6,June
himself
and son
particularly
and wife. His inincluding
analgesic
1975
up
to
(Percodan)
633
8
ECT
FOR
CHRONIC
TABLE
PAIN
I
Clinical
Characteristics
ofSix
Patients
with
Chronic
Pain
and
Depression
Sex
Age
I 2
M F
Married Married
47 55
Head Head
5 years 20 years
3
F
Single
64
Chest
IOmonths
Patient
Comfortable
.
.
Duration
Location of Pain
Marital Status
of Pain
Overall
.
Hamil
During
Acute
Observation
ton
Score
Subjectively Depressed
Personality Diagnosis
Pre-ECT
Post-ECT
40 26
3 14
Yes No
Passive-dependent, Passive-dependent,
59
5
Yes
Mixed, with passive-aggressive and hysterical elements. moderate severe Hysterical personality. moderate
Responders
4
F
52
Married
Back. face, head,
0 2 years
No Intermittently so No
l0months
6 months
6 months
No
53
II
Yes
mild mild
to
chest Nonresponders 5 6
F
Married
73
Face
20 years
2 years
Intermittently so
32
19
No
F
Married
68
Face, head
30 years
2 years
Yes
25
22
No
Hysterical personality. moderate to severe Passive-aggressive dcments, moderate to severe
and antidepressant medication. He was hospitalized because of addiction to the analgesic and decreasing work performance. Mental status examination revealed a depressed man with sad facies, stooped posture, and slow speech. He constantly meferred to his headaches and appealed to the examiner for some medication. He admitted to symptoms of depression only during specific questioning. He scored 40 on the Hamilton depres-
the
around, her husband reported and she reported no recurrence
that she was strikingly of pain.
sion scale.
Case 3. A 64-year-old single on a psychiatric unit to which
she had been
medical
been
Following a series of 6 unilateral ECTs, the patient’s ache disappeared and his Hamilton score fell to essentially On 2 occasions in the year of follow-up he has become jectively
depressed
and
has
been
given
a 6-week
mg of doxepin at bedtime. He has not missed since his discharge from the hospital, and his not recurred. Case 2. A 55-year-old salesman
graine” tartrate
analgesic mines
not
only
(Cafergot) She stated
and
to reduce
her
her
pain
hospitalization
but
was
move to a new location about home, as well as by the Food stringent
control
a day headaches
have
to “get
narcotic ampheta-
me going,”
and
20 years. She had 2 years prior to ad-
triggered
in part
by her
200 miles away from her previous and Drug Administration’s more
of amphetamines,
which
made
it difficult
for
her to obtain them. Her internist, noting that she appeared depressed, treated her with up to 250 mg of amitniptyline, at bedtime, for several months prior to ECT; there was no change in her symptomatology. During her mental status examination she was extremely reluctant to talk to the examiner and insisted that the lights be turned
off
during
the
interview
because
they
exacerbated
her
“migraine.” When she did talk, she spoke of missing her previous home and her “pep pills,” and she complained that her husband was away much of the time-yet denied being the type who would complain. Despite an elevated Hamilton score of 26,
634
A m J Psychiatry
132:6, June 1975
denied
being
depressed
her depression once her mood brightened
6-month
follow-up
ward,
where
pain.
Initially
closer
questioning
she
and ready previous
her
she
seemed
to fall out.
score
quite
Her
“rotten”
and
6 unilateral very
that
pleasant
capable,
ensuing
with
from
severe
a
chest but
was
“split
on
in two”
was 59. There depression.
oftime
was no Mood-
to treat
her.
After
metamorphosis
quite
situation.
mother
in consultation
score
free and had a Hamilton
A 52-year-old
up and
improved,
transferred
somewhat
living
Case 4. of her life 6 months set of pain pain over
was
ofsevene
although
able to cope
was symptom
seen
heart
a surprising
pending
in her
to talk
without any success. When she replied that her brain was
who was subsequently change
able
psychologically,
her
be a waste
she had
and
was
intact
that history
it would
ECTs
only
14, she
admitted
Hamilton
or family
was
woman
had
was
had begun. After 6 unilateral hen headache disappeared. At
Hamilton
she claimed
personal
and
ECT and
elevating drugs were prescribed, ECT was suggested to the patient,
and a semisynthetic that she also needed
she had used them intermittently for almost lived near her family for her entire life until mission,
sub150 of work of
married mother of two and wife of a intermittently for 20 years of “miwas relieved somewhat by ergotamine
complained headache, which had
and caffeine (Percodan).
course
headzero.
patient
about ECTs
into
lonely,
effectively
with
1-year
follow-up
At
score
of five had
a
woman,
an imshe
of 5. been
well
for
most
with the exception of a hysterectomy at age 42. About prior to seeing her physician, she experienced the onin her upper night cheek with occasional “shooting the top of my head and down my spine.” During the
several
months
her
appetite
diminished,
she
lost
ap-
proximately 15 pounds, and her interest in her everyday household chores diminished to the point where she was spending her days in bed. She complained to her physician of poor appetite and loss of interest in food, occasional palpitations, shortness of breath, and a “full, uncomfortable feeling” in the upper left side of her chest. Her physician noted that she appeared sad, and when he asked her specifically if she was depressed, she admitted that she was but added emphatically that it was due to her severe pain and that her problems were certainly physical. After an extensive work-up her physician prescribed a regimen of
MICHEL
imipramine,
tenly
but
it
ofdizziness
After
was
and
the
discontinued
dry
patient
after
she
bit-
complained
had
FIGURE
I
Pretreatment
mouth.
undergone
many
complete
R. MANDEL
Mean
Scores
on Individual
Hamilton
Scale
Items’
examResponders
inations by various specialists and continued to complain of severe pain, her physician arranged for an interview with her and her husband. Her husband reported many bizarre symptoms and increased suspiciousness. He also said that the patient had talked about being punished, about having a brain tumor, and had spoken ofdeath on several occasions. It became somewhat
E:J
Nonresponders
a
>
C >, U C
0 0
E a)
more clear at this point vere and even delusional
that her pain might be a screen for a seaffective illness, and a psychiatric consultation was arranged. The patient’s Hamilton score was 53. The patient received a total of 10 unilateral ECTs, with initial brightening of mood and disappearance of vegetative signs and
4r-
r
;g .?
:
a)
C
c
:
a
;
(3
n
E
n
D
5
2
symptoms. Her pain persisted until the seventh ECT and then disappeared. At 6-month follow-up the patient was essentially back to her former normal self and was asymptomatic. Her
husband
reported
that
she
occasionally
numbness in the areas previously complaints were transient. Her low-up was I I.
complained
described Hamilton
of mild
as painful, but score at 6-month
these fol-
4
73-year-old wife of a dentist developed maxillary facial pain 20 years prior to psychiatric consultation, after her discovery of her husband’s brief affair some years earlier. After consulting various physicians at that time, she was able to “tolerate” the pain, which was relieved by intermittent use of carbamazepine (Tegretol). Shortly after her husband’s semiretirement 2 years prior to psychiatric consultation, her pain worsened and she withdrew to her bed, with his almost constant ministering to her. One year prior to her admission, she was admitted to a psychiatric hospital under somewhat vague cincumstances and received 12 ECTs with quite striking improvement. a neurosurgical medication
prior
to her referral
evaluation, administened,
was
to another
hen pain slowly but multiple
hospital
.
“like
returned. Tricyclic side effects devel-
She suffered from marked constipation and appetite. Her Hamilton score was 32. After her Hamilton score fell to 15, and her pain but did not disappear. Shortly after her began to complain of pain once again. At
a slap.”
and 7 unilateral ECTs decreased somewhat arrival home she loss
of
weight
6-month follow-up her condition was essentially from what it had been originally; her Hamilton score 6. A 68-year-old
bank and pain in the right
(‘use
headaches neurosurgical
consultation
local
physician
was
19.
after
of for
unsuc-
cessful treatment with many therapies, including acupuncture and tric’yclic antidepressants. Her pain had intensified over the past 2 years since the retirement of her husband and their close involvement in an antique business. Her medical history revealed that she had cared for hen ailing mother until the latter’s death and that at age 35 she had married the vice-president of the bank in which she worked. Since her husband’s retirement she
had
spent
and much
much
of their
lief for her pain.
She
appeared
was begun antidepressant
condition
of her
The
changed
in bed,
focused
with
him
on searching
caring
for her,
for new re-
patient’s
depressed
on a course therapy.
had
time
life together
1-lamilton score was 25. on mental status examination and of ECT after an unsuccessful trial on After 9 unilateral ECTs the patient’s
little;
she returned
home
.c
0
0 0
a E
C 0
a
c
>
nI
,
-
oa
0
.C n
C
no
n
E
,
a. E
n N
-
‘
C 0
a
C
a)
I1l
HI
0
.E
14
15
16
HAMILTON *Higher
scores
the same further
I)ISC
indicate
increased
situation,
the referring time
in bed.
17
SCALE
psychiatric
At 5-month
19
0
20
21
ITEMS
or medical
follow-up
and had remained Her
18
a
pathology.
refusing
hospital.
consultation
of her
o
JiLWLLLL
012J
‘
(0
Hamilton
at home,
score
follow-up
she had
at that
spending time
at
not sought was
most 22.
U.SSION
unchanged
teller with a 30-year history side of her face was referred
by her
E +-
for
oped, prohibiting its further use. On examination, her behavior was coquettish and mildly inappropriate, with intermittent sadness, but there was no cvidence of dementia. She repeatedly referred to her pain as burning
0 C 0
,
Case 5. The
the 12 months
C 0
,
Nonresponders
Over
10
-
to essentially
Figure 1 presents the responders’ and nonresponders’ mean scores on individual Hamilton items. This is an uncontrolled study, and conclusions must be tentative. However, the Hamilton scores suggest that ECT may alleviate both the pain and depression ofdepressed, chronic-pain patients who present with guilt, psychomotor retardation,
suicidal
ideation,
increased
agitation,
anxiety,
depersonalization, and paranoia. It is also ofinterest that the two nonresponders were the oldest in the group and had suffered from pain for 20 years or more. The cases presented highlight the problem of potentially undertmeated depressions with somatic symptoms, in both medical and surgical settings. Our experience with these patients confirms Bradley’s suggestion (12) that the onset of pain coincident with depression is melated to relief of both with ECT and Ziegler and associates’ impression (6) that conversion symptoms includAmJ
Psychiatry
132.6,June
1975
635
PROFESSIONALS
WORKING
OVERSEAS
ing pain in patients over the age of 40 may be related to depression. These cases are also presented to demonstrate that the application of an easily administered depression rating scale may be useful in documenting depressive illness in this group. It should be stressed that these selected patients with high Hamilton depression scores were followed closely, with attention to psychosocial set, and provisions for adequate follow-up and family support were made in each case. Difficulties may loom ahead for an uncritical application of ECT without attention to these matters. These patients represent one subgroup of a chronicpain population presently under study, and this report is intended to alert physicians to the possible use of ECT in depressed patients presenting with pain syndromes. It appears from these cases that ECT may alleviate the symptoms of depression and pain in a significant number of patients who have been unsuccessfully treated with antidepressant medication.
2.
Mechanic of bodily
D: Social
psychologic
factors
affecting
tions: 7. 8. 9.
a clinical
shock 10.
study.
Am J Psychiatry
Klerman GL: Research 24:305-319, 1971 Merskey H, Hester RA: chotropic drugs. Postgrad Pisetsky JE: Disappearance Von
treatment. Hagen
KO:
and
report
nism
165:773-777,
1 1. Weinstein therapy
in
1 16:901-909,
depression.
Arch
The
Engel GL: 26:899-918,
Psychogenic 1959
Depressive
Working B
LUCY
pain
and
the
pain-prone
Syndrome:
patient.
Am
J Med
A Follow-Up
Psychiatry
of eight
cases
treated
with electroshock.
JAMA
1957
EA, Kahn RI, Bergman PS: Effect of electroconvulsive on intractable pain. Arch Neurol Psychiatry 81:37-42,
23:56-62,
with
the
J Neurol
depressive Neurosurg
1960
14. Feighner JP, Robins E, Guze SB, et at: Diagnostic criteria for use in psychiatric research. Arch Gen Psychiatry 26:57-63, 1972
Study
of 130 Professionals
Overseas JANE
KING,
MI).
A four-yearfollow-up ofprofessionalpersonnel who had been working overseas indicates that the depressive syndrome was the most common diagnosable psychiatric illness in this population. The study also shows that in this context the syndrome had a goodprognosis. It therefore seems reasonable not to exclude persons with diagnosable depression from assignment abroad but, rather, to identtfy the syndrome and recommend necessary treatment.
INTERVIEWS HAVE BEEN CONDUCTED with 130 professional personnel from the United States working in 12 countries in Asia, Africa, or Latin America before and after their terms of service overseas, which lasted from two to six years (mean, four years). This has made possible a follow-up study of psychiatric symptoms in persons who were chosen for work overseas because they
636
1960 Gen
The treatment of chronic pain with psyMed J 48:594-598, 1972 of painful phantom limbs after electric Am J Psychiatry 102:599-601, 1946 Chronic intolerable pain-discussion ofits mecha-
1959 Bradley ii: Severe localized pain associated syndrome. Br J Psychiatry 109:741 --745, 1963 13. Hamilton M: A rating scale for depression.
Psychiatry I.
presentation
112:651-659, 1966 5. Davis D, Weiss MA: Malingering and asSociated syndromes, in American Handbook of Psychiatry, revised 2nd ed, vol 3. Edited by Arieti S. New York, Basic Books, 1974, pp 270-287 6. Ziegler FJ, Imboden JB, Meyer E: Contemporary conversion reac-
12. REFERENCES
the
complaints. N Engl J Med 286: 1 132-1 139, 1972 3. Lipsitt DR: Medical and psychologic characteristics of “crocks.” Psychiatry Med 1:15-25, 1970 4. Lascelles RG: Atypical facial pain and depression. Br J Psychiatry
AmJ
Psychiatry
132:6,June
1975
were functioning well in professional moles and who were placed in an environment where they would face cultural shock (1). As stated previously in a report on the initial interviews of 104 candidates for service overseas (2), the most common psychiatric syndrome seen was depression. This brief report will focus on affective and other psychiatric syndromes, family history of psychiatric illness, and certain aspects of living and work situations abroad.
At the time this paper was written, Dr. King was Associate Professor, Department of Psychiatry, Washington University School of Medicine, St. louis, Mo. She is now Professor, Departments of Psychiatry and Pharmacology, Medical College of Virginia, Virginia Commonwealth
University,
Richmond,
partment
This Career Mental
Va. Address
of Psychiatry,
work
MCV
was supported
Development Health.
The author would like ton University Medical erature search.
Station,
in part by Award MH-l9394 to thank Library,
reprint
requests
Richmond,
to her at the DcVa.
23298.
grant MH-13002 and from the National
Ms. Margaret S. Cummings, St. louis, Mo., for assistance
Research
Institute
of
Washingin the lit-
