Attending Physician Pain Institute of Long Island Port Jefferson, New York, United States
Case Diagnosis: 90-year-old male with Major Depressive Disorder (MDD) visits pain management for rectal pain lasting two years.
Case Description: At the time of consult patient was taking Percocet for pain with minimal relief. He describes the pain as a throbbing constant ache, and progressively getting worse. At times he is unable to sit down because the pain is so severe. Patient was started on gabapentin 300mg TID and scheduled for a ganglion impar block. He received no relief from the gabapentin so it was discontinued, and post block, patient stated he had about 60% pain relief for 1 week. A 2nd and 3rd injection were performed with 60 and 10 percent relief respectively. Due to minimal relief no more blocks were attempted. In the following months the patient visited a psychiatry specialist who recommended Electroconvulsive Therapy (ECT). He received 2 treatments a week for 3 weeks with complete resolution of all rectal pain as well as his depression.
Discussions: The mechanism by which ECT improves chronic pain is not clear. ECT causes changes in the availability of neurotransmitters and causes a consistent increase in the amount of endorphins in the central nervous system; leading to cell growth and increase in synaptic connectivity. ECT also appears to increase pain threshold and pain tolerance in patients with MDD, along with improvements in depressive symptoms.
Conclusions: This case describes a patient with major depression and severe rectal pain refractory to multimodal pharmacologic and interventional therapies with great response to Electroconvulsive Therapy. Since beginning ECT, his rectal pain has not returned and patient’s function and quality of life has greatly improved. ECT is a safe alternative for patients with MDD and have chronic pain that is refractory to both pharmaceutical and interventional therapies.