Abstract
Electroconvulsive therapy (ECT) is highly effective for the treatment of refractory major depression [1], [2], but a high rate of relapse after discontinuation of ECT has been reported [3]. Although the effectiveness of nortriptyline and lithium combination has been reported for maintenance after ECT sessions, the relapse rate is still high, particularly during the first month of continuation therapy [4]. The development of more effective long-term relapse-prevention therapy is needed. We report here a case of refractory depression, where the addition of lithium to milnacipran after ECT sessions effectively maintained the improvements in depressive symptoms and no further ECT treatments were required.
Mrs A, a 63-year-old Japanese woman had no previous psychiatric or medical illness and no known family history of mental illness. Two months before admission, she developed a major depressive disorder. She had severe depressive mood, insomnia, and the loss of appetite, and hospitalization was needed because of her suicide attempt and mood-congruent delusions. She was resistant to treatment with various antidepressants, including amitriptyline, amoxapine, fluvoxamine, milnacipran and augmentation with risperidone, levothyroxine (thyroid hormone) or methylphenidate. ECT in conjunction with milnacipran treatment resulted in a full resolution of symptoms but she relapsed within 2 weeks, requiring a further course of ECT. Augmentation therapy of lithium carbonate (400 mg/day) was selected after the last ECT. The combined use of lithium and milnacipran has maintained her recovery from depression without adverse reactions, and no further ECT has been required.
After the discontinuation of ECT, the best choice of continuation pharmacotherapy is still unclear. Lithium augmentation of tricyclic antidepressants (TCAs) has been recommended [4], [5], but our patient's tolerance of TCAs was low. Several new types of antidepressants, such as selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs), are now marketed. Compared with the use of milnacipran and ECT, the addition of lithium provided superior efficacy in the maintenance treatment of this case with refractory depression. SNRIs generally have high tolerability profile and also have efficacy similar to that of TCAs [6–8]. SNRIs include milnacipran, venlafaxine, and duloxetine. In Japan, only milnacipran is currently used. Although milnacipran should be considered a promising agent for the treatment of patients with major depressive disorder [7], the efficacy of its use in augmentation therapy for refractory depression is not known. To our knowledge, this is the first report that indicates the augmenting efficacy of lithium in milnacipran-resistant major depression. Although further studies are required in order to confirm its effects, lithium augmentation with milnacipran could be considered in patients with refractory major depression and in maintenance after ECT.