Treatment of Depression With Methylphenidate in Patients Difficult to Wean From Mechanical Ventilation in the Intensive Care Unit

Background: Mechanical ventilation is oftenrequired to support patients in the intensive care unit (ICU)with life-threatening cardiovascular, respiratory, orneuromuscular disorders. Occasionally, difficulties related toweaning patients from this support occur owing to depression. Thetraditional and newer-generation antidepressant drugs have arelatively long latency of response that interferes withrehabilitation attempts in the ICU. Psychostimulants such asmethylphenidate show a rapid onset of antidepressant activity anda benign side effect profile.

Method: As consulting psychiatrists in theconsultation-liaison service of a university hospital, we treated7 patients with complex ICU courses presenting prolongedmechanical ventilation and psychomotor retardation associatedwith markedly depressed mood (DSM-IV criteria) by giving themmethylphenidate. Methylphenidate was started on the first day ata dose of 2.5 mg p.o. in the morning and was increased by 2.5 mgeach day with twice-a-day dosing in the morning and at noon untilthe patient responded or showed side effects. A maximum dose of15 mg/day was not exceeded. Outcome evaluation was performedusing the Clinical Global Impressions scale.

Results: Five (71%) of 7 patients showed markedor moderate improvement in mood and activity within 3 to 4 days,and discontinuation of ventilator support was achieved within 8to 14 days. Side effects with these 5 patients were notencountered. Of the remaining 2 patients (29%), 1 developedpsychomotor agitation and anxiety within 4 days. Another patientshowed only minimal improvement with regard to activity.

Conclusion: Methylphenidate might be a rapidlyeffective and safe treatment for depression in difficult-to-weanpatients hospitalized for life-threatening medical illness in theICU. Implications for future research for this population ofpatients warrant formal randomized, prospective, clinicalcase-control evaluation.