A Patient With Electroconvulsive Therapy–resistant Major Depressive Disorder With a Full Response to Heated Yoga: A Case Report

Abstract

Depression remains difficult to treat as a result of less than optimal efficacy and troublesome side effects of antidepressants. The authors present the case of a patient with treatment-resistant depression with melancholic features who had previously been unresponsive to electroconvulsive therapy (ECT) plus an antidepressant regimen but whose condition fully remitted with the addition of a standardized form of heated hatha yoga (HY; Bikram yoga) practiced in a room heated to 105°F. The patient was a 28-year-old woman who underwent 8 weeks of HY as part of a randomized controlled trial of HY for depression while continuing her antidepressant treatment. The patient was asked to attend a minimum of 2 weekly, 90-minute HY classes. After 8 weeks (12 classes in total), the patient no longer met the criteria for a major depressive episode with melancholic features, per Mini-International Neuropsychiatric Interview (MINI) criteria. Her depressive symptoms had improved dramatically, with Inventory of Depressive Symptomatology, Clinician-Rated (IDS-C 30 ), and Hamilton Depression Rating Scale (HAM-D 28 ) scores decreasing from 28 at baseline to 3, and from 28 at baseline to 4, respectively, indicating remission. This patient's ECT-resistant depression remitted with the addition of HY to her antidepressant regimen. Because of her youth and athleticism, this patient was likely well suited to this rigorous form of yoga. Further research is needed to explore HY as a potential intervention for treatmentresistant depression.

Commentary: Treatment-resistant Depression: Considerations Related to ECT and Ketamine

“…3 The 3 cases presented in this issue of the Journal deal with an array of clinical considerations in treating patients with TRD, including the use of ECT in a patient with a history of liver transplantation, the use of heated yoga (HY) in a patient nonresponsive to ECT, and a case of IN ketamine abuse. [4][5][6] Gunther et al 4 described the case of a 71-year-old man who had had an orthotopic liver transplant for hepatitis B and liver failure 26 years earlier and was admitted with a 2-month episode of major depressive disorder, severe, with psychotic features, that had not responded to an initial course of antidepressants. The authors cite the high rates of depression among patients after liver transplantation.…”

“…Sakurai et al 5 reported the case of a 28-year-old woman with a past mild traumatic brain injury and chronic TRD. The patient had had multiple (56) previous ECT treatments but continued to have only partial response to several antidepressants and maintenance ECT.…”

“…She was evaluated and treated with a course of twice-weekly 90-minute HY and experienced a remission of her depression. 5 This research group had previously studied HY as a treatment for depression in an open-label pilot study, 8 and they are now conducting an ongoing randomized controlled trial (ClinicalTrials.gov Identifier: NCT02607514). While there are limitations to the utility of HY in TRD, including questions about adherence, comorbid use of antipsychotics and stimulants, and applicability of use in populations other than healthy adults, there may be benefit to the ongoing study of nonpharmacologic approaches like HY as adjuncts to medication, brain stimulation, and psychotherapy for patients with persisting TRD.…”

“…Patients with TRD whose illnesses are nonresponsive to first-line and second-line treatments may opt to be evaluated for brain stimulation such as electroconvulsive therapy (ECT) or for ketamine or esketamine, the latter of which was approved in intranasal (IN) form for TRD 3. The 3 cases presented in this issue of the Journal deal with an array of clinical considerations in treating patients with TRD, including the use of ECT in a patient with a history of liver transplantation, the use of heated yoga (HY) in a patient nonresponsive to ECT, and a case of IN ketamine abuse 4–6…”

“…The patient had had multiple (56) previous ECT treatments but continued to have only partial response to several antidepressants and maintenance ECT. She was evaluated and treated with a course of twice-weekly 90-minute HY and experienced a remission of her depression 5. This research group had previously studied HY as a treatment for depression in an open-label pilot study,8 and they are now conducting an ongoing randomized controlled trial (ClinicalTrials.gov Identifier: NCT02607514).…”