The Use of ECT in a Geriatric Patient with a Deep Brain Stimulator

Abstract

<h3>Introduction</h3> Electroconvulsive therapy (ECT) is a commonly used and effective treatment for major depressive disorder with psychosis, especially in the geriatric population. Depressive disorders have significant prevalence in those with movement disorders including Parkinson's disease. Deep-brain stimulators are an effective treatment for Parkinson's disease, however, few cases in the literature exist about the use of ECT in patients with deep-brain stimulators. <h3>Methods</h3> A 68-year-old man with Parkinson's disease with a deep-brain stimulator (DBS) is seen in an outpatient geriatric psychiatry clinic. He has severe major depressive disorder with psychosis. The patient's clinical features include depressed mood, hopelessness, anhedonia, poor sleep, and poor appetite with weight loss. He endorses delusions of worsening physical and functional ability as well as delusions of abandonment and impoverishment. The patient experienced suicidal thinking and had impulsive para-suicidal behavior. The patient's symptoms are minimally responsive to treatment with antidepressants (Escitalopram, Mirtazapine, and Duloxetine) as well as psychotherapy. The patient's Parkinson's disease is treated with carbidopa-levodopa and a St. Jude DBS in his subthalamic nucleus, which was placed almost two years earlier. An ECT consultation was pursued in conjunction with discussion with the patient's neurologist. The patient begins undergoing acute bifrontal ECT with his DBS switched off for his treatments. <h3>Results</h3> The patient has, thus far, had 12 bifrontal acute phase ECT treatments, with the first 10 treatments occurring biweekly and then weekly. He is tolerating ECT well with minimal cognitive impairment immediately after the treatment and no complications relating to his DBS. After three treatments, the patient began experiencing significant improvements in mood, appetite, and sleep noted by himself and collateral sources. After 10 treatments the patient's suicidality and psychotic symptoms had resolved. The patient is much more active and has an improved level of functioning. His family notes that after over a year of severe depression, he finally is "back to himself." <h3>Conclusions</h3> ECT is an appropriate and effective treatment for major depressive disorder with psychosis in patients with concomitant Parkinson's disease who have a DBS. Although there are very few case reports of prescribing ECT to treat patients with Parkinson's disease that have a DBS device, this case demonstrates that it is a safe and efficacious treatment that should be considered. It is especially important to consider this treatment if there is a lack of response to antidepressants. When patients with DBS are not offered ECT due to reluctance and safety concerns, these patients are deprived of a valuable treatment option. <h3>Funding</h3> Not applicable