Electroconvulsive Therapy as an Adjunct to Treating Metastatic Prostate Cancer: Case Report

Mr. X is a 73-year-old, recently widowed man with treatment-resistant major depressive disorder with psychotic features, generalized anxiety disorder, and alcohol use disorder. Ten years earlier he completed external-beam radiation for localized prostate cancer. Over the 4 months before admission he withdrew from friends, stopped oncologic follow-up, and lost more than 10 kg. He presented to the emergency department with worsening suicidal ideation, as well as delusional and ruminative thoughts, such as the idea that “there is a conspiracy against [him],” that he “endangered [his] entire family,” and that he was “so ugly people cannot stand to look at [him].” On examination, he appeared cachectic and anxious. Blood pressure measured 192/120 mmHg, his labs revealed a creatinine of 2.0 mg/dL and albumin of 2.9 g/dL. A CT scan of his chest demonstrated innumerable osteoblastic lesions within the ribs and spine; a nuclear bone scan confirmed diffuse metastases, consistent with a recurrence of his prostate cancer. Cognitive testing showed intact orientation with marked psychomotor slowing. His psychiatric medication list previously included sertraline, mirtazapine, quetiapine, paliperidone, lorazepam, and olanzapine. His outpatient psychiatrist had stopped many of these medications due to his significant lethargy and sedation. At presentation, his medication regimen consisted of sertraline 200 mg daily and olanzapine 10 mg nightly without benefit. Mr. X reported to the team that he was inconsistent with his medication adherence since they “make him feel like a zombie.” He also reported worsening avolition. In the weeks leading up to his admission, he stopped eating or taking his medications, restricted himself to his bed, and relapsed on his alcohol use. The care team contacted his older brother, who traveled from out of state to provide collateral history, support, and participate in the treatment plan. Given the severity of his psychotic depression, functional decline, medical comorbidities, and history of poor medication tolerance and adherence, the team determined that electroconvulsive therapy (ECT) offered the safest and most effective treatment. Pharmacologic options were limited by his renal impairment, frailty, and prior nonresponse to multiple antidepressants and antipsychotics. ECT was initiated on an urgent inpatient basis with bitemporal electrode placement, administered three times per week. He tolerated the procedure well, with transient postictal confusion resolving within hours. Over the course of eight treatments, Mr. X demonstrated progressive improvement: his delusional guilt diminished, suicidal ideation abated, appetite improved, and he began to ambulate and participate more actively in his own care. By the completion of the acute course, he had regained the capacity for outpatient oncologic follow-up and engaged in discussions about palliative care with his brother and the treatment team. We chose this case because it highlights the challenges of caring for a patient with severe physical and mental illness. Additionally, this case demonstrates that treating a patient's psychiatric and medical diagnoses must go hand in hand. Mr. X suffered from treatment-resistant depression with psychotic features, characterized by ruminative guilt, paranoia, and suicidality. His psychiatric illness drove functional decline and impaired his ability to engage in cancer care (Mind). He had a history of burdensome polypharmacy with multiple antidepressants and antipsychotics, which caused sedation and poor adherence. His limited benefit and side-effect burden from medications highlighted the need for an alternative approach (Medications). Recurrent metastatic prostate cancer compounded his psychiatric presentation. Physical symptoms of his cancer were often clouded by his psychiatric history, making diagnosis and treatment more challenging (Multicomplexity). A combination of avolition, cachexia, and withdrawal left him bedbound, nutritionally depleted, and unable to care for himself. These physical consequences of psychiatric illness accelerated his functional decline (Mobility). Mr. X expressed a desire to regain dignity and independence. Restoring his agency and capacity for treatment was essential to honoring his values and goals of care (Matters Most) (Figure 1). First line treatment of depression with psychotic features in older patients is much the same as in adult aged individuals, that being multiple psychotropic medications [1]. This is in spite of how ECT displays remarkable efficacy in treating this illness [2]. ECT works notably well in the treatment of psychotic depression, with remission rates in late-life psychotic depression exceeding those seen in nonpsychotic depression (e.g., 68.9% vs. 51.0%) [3]. Clinicians are often afraid to use ECT in older patients due to concerns with other medical comorbidities and frailty in this patient population [4]. The evidence does not support this hesitance, however. Regarding its safety, cognitive side effects of ECT are generally transient, and older adults may experience fewer cognitive adverse effects than younger patients [4]. Antipsychotics remain first-line for treating schizophrenia in older adults, with risperidone generally preferred (followed by olanzapine, quetiapine, and aripiprazole) [5]. Additionally, current guidance recommends lower doses in this population. However, these recommendations rest on limited evidence. Few studies focus on older adults, and existing trials are smaller in size [6]. Moreover, the Beers Criteria advise avoiding first- and second-generation antipsychotics in older adults because of a dose-dependent increase in overall mortality risk, which is largely attributable to cardiovascular events, falls, fractures, pulmonary emboli, and pneumonia [7, 8]. In the case of Mr. X, the shortcomings of antipsychotics were apparent. Each of the antipsychotic medications trialed was discontinued either due to side effects or lack of efficacy, thus leading the team to consider ECT. ECT functioned not only as a treatment for Mr. X's severe depression, but also as an adjunct to his oncologic care. Rapid mood stabilization reversed his avolition and self-neglect, enabling him to eat, adhere to his cancer medications, and attend time-sensitive oncology appointments. His cancer treatment regimen requires a level of cognitive and motivational capacity that he did not have before, which ECT was able to give him. Indirectly, ECT advanced the management of his metastatic prostate cancer and shows how psychiatric intervention can also lead to improvements in non-psychiatric outcomes. Mr. X's course also highlights a bidirectional, self-reinforcing relationship between depression and malignancy. His profound mood symptoms precipitated social withdrawal and loss of follow-up, delaying the detection of his metastases. Conversely, cachexia, the existential burden of a cancer recurrence, and depressive symptoms from the cancer itself [3] amplified his psychiatric illness. Recognizing and interrupting this feedback loop was essential to preventing the deterioration of his condition on both fronts, mental and oncologic. This case illustrates the degree to which psychiatric illness can complicate outcomes of non-psychiatric disease. When depressive or psychotic symptoms complicate treatments, ECT may be considered as a bridge to treatment adherence as opposed to a last resort of treating refractory psychiatric symptoms. Additionally, deliberate involvement of family support in specific ways can target problems specific to patients. Mr. X completed a 12-session course of ECT, leading to a marked improvement in his mood, functioning, and ability to care for himself. At discharge, he was psychiatrically stable and began attending outpatient ECT and oncology appointments. With ongoing support from his brother, he was able to engage in treatment and move forward with his care plan. Four months later, he was seen in the hallways of the hospital on the way to his outpatient oncology appointments with markedly improved affect and mood. Concept and design: Jake Teich, Nicholas A. Smith, and Simon Shugar. Paper drafting/revision: Jake Teich, Nicholas A. Smith, and Simon Shugar. The authors have nothing to report. No funding from outside sources was used in the culmination of this project. This report was previously presented at the Florida Medical Association Fall 2024 Poster Symposium, but has never gone to print, or otherwise been submitted or published elsewhere. The authors declare no conflicts of interest.