Pharmacological Re‐Optimization With Venlafaxine in Two Elderly Patients With Severe Major Depressive Disorder Considered for Electroconvulsive Therapy: A Two‐Patient Case Report

Electroconvulsive therapy (ECT) effectively treats severe late-life depression but is often approached with caution in very elderly patients with cardiac or cerebrovascular disease. Venlafaxine, a serotonin-norepinephrine reuptake inhibitor with dose-dependent transporter engagement, may be useful for anxious depression with psychomotor disturbance, yet data are limited. We describe two elderly inpatients with severe major depressive disorder for whom ECT was planned. Case 1 was a man in his late 70s with complete atrioventricular block and a permanent pacemaker who relapsed despite long-term duloxetine-based outpatient therapy. Case 2 was a woman in her late 80s with prior clipping of an unruptured middle cerebral artery aneurysm whose symptoms worsened despite outpatient mirtazapine and risperidone with the addition of duloxetine. In both cases, duloxetine was cross-tapered to venlafaxine extended-release while mirtazapine was continued, and venlafaxine ER was titrated to 150 mg/day as a closely monitored, time-limited pharmacological re-optimization step during ECT preparation. Symptoms improved; the 21-item GRID-Hamilton Depression Rating Scale total scores fell into the remission range. Appetite and oral intake improved, and planned ECT was canceled. These cases highlight the potential value of individualized pharmacological re-evaluation, including SNRI switching, even when ECT is being considered.