ECT in Delusional Depression With Multiple Sclerosis

Ms. A, a 51-year-old woman, had her first multiple sclerosis symptoms 7 years ago. A magnetic resonance imaging (MRI) proton-density-weighted axial brain scan performed 1 year later at a specialized center for multiple sclerosis showed ventricular enlargement and several multiple white matter lesions in the right part of the brainstem and bilaterally in the periventricular and subcortical areas.

Five years after the onset of multiple sclerosis, Ms. A was first hospitalized in the psychiatric ward for major depression and responded well to sertraline, 100 mg/day. One year later, a significant deterioration required hospitalization in the neurology ward followed by hospitalization in the psychiatric ward for severe catatonic delusional major depression (DSM-IV-TR) necessitating tube feeding.

ECT was required to obtain rapid improvement in this life-threatening situation. A pre-ECT brain computerized tomography scan showed moderate cortical and subcortical atrophy. ECT stimuli were delivered bilaterally by a Thymatron Tm, DG-100%=504 microcoulomb (brief-pulse) device. Anesthesia was induced with intravenous methohexital (1 mg/kg) followed by intravenous succinylcholine (1 mg/kg) and oxygenation with 100% oxygen. Improvement was seen after the third session and persisted during the subsequent 11 consolidation ECT pulse sessions. Ms. A’s total score on the 17-Item Hamilton Depression Rating Scale was 26 before ECT and 10 after ECT. Haloperidol (15 mg/day) was also prescribed.

Neither significant confusion nor memory impairment suggesting the encephalopathic effect of ECT was observed, and there was neither clinical evidence of exacerbation nor remission of neurological multiple sclerosis symptoms. Brain MRI after ECT showed no change compared to the first MRI performed before ECT. Three months later, Ms. A was still in remission while being treated with venlafaxine, 100 mg/day, and haloperidol, 5 mg/day.