Innovations In Clinical Neuroscience

JAN-FEB 2018

A peer-reviewed, evidence-based journal for clinicians in the field of neuroscience

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C A S E S E R I E S 26 ICNS Innovations in Clinical Neuroscience • January–February 2018 • Volume 15 • Number 1–2 was still symptom free from depression and PD. Case 5 . Ms. E, 52 years old, presented to our clinic with stiffness in her right arm and right leg, which she reported had been present for five years and for which she had not undergone any treatment. She also reported having symptoms of depression for the past 1.5 years, including sadness of mood, worries about future, decreased interest in activities, decreased sleep and appetite, and easy fatigability. Both her body stiffness and depressive symptoms worsened to the extent that she would remain in bed, had difficulty in speech, and would pass stool and urine in bed. She was admitted to the neurology ward, was diagnosed with PD, and was prescribed levodopa, carbidopa, and entacapone. She had mild improvement in that she could speak but reported feelings of fearfulness, suspiciousness, hopelessness, helplessness, and a wish to die. She was then admitted to the psychiatry ward. She was diagnosed with psychosis (as per ICD-10 criteria) and was offered ECT. Baseline assessment revealed an HDRS score of 27 and an UPDRS score of 38. Ms. E underwent 15 sessions of ECT over the course of one month. At the time of discharge, she had a HDRS score of 12 and UPDRS score of 23 and was fully mobile, could perform ALDs without assistance, and reported an absence of fearfulness and suspiciousness. She was prescribed venlafaxine, quetiapine, levodopa, carbidopa, and entacapone. She remained stable at the one-year followup. Case 6 . Mr. F, 60 years old, had a 35-year history of recurrent depressive disorder, and upon presentation reported that he had been experiencing a relapse for the past two years. He reported symptoms of sadness, crying spells, excessive worries, decreased confidence, pessimistic view of future, and poor sleep and appetite. His symptoms waxed and waned despite treatment with antidepressants. For the previous year, his depressive symptoms had worsened, and he reported having suicidal thoughts. Three months prior to the presentation, he also started experiencing tremors in both hands, slowness in initiating and maintaining movements, and slurred speech. A day prior to presentation, he attempted suicide and was subsequently admitted to the psychiatry inpatient unit. Mental status examination at the time of admission showed that he had depressed affect, feelings of hopelessness and helplessness, death wishes, and suicidal ideations. A physical examination revealed presence of rigidity and tremors in both upper limbs, but more so on left side. The patient was not taking medications for his PD. Because of significant risk for self-harm, ECT was initiated. He was administered nine sessions of ECT over one month. His HDRS score before starting ECT was 37 and at the end of ECT was 11. His UPDRS score decreased from 44 to 16. He reported relief from depressive symptoms as well as from symptoms of PD. There was no rigidity or tremors at the time of discharge. He was released on bupropion, along with medicine for hypertension and diabetes mellitus. No PD medicine was initiated at the time of discharge. He was advised to follow up in neurology outpatient department (OPD) if the tremors and rigidity returned. In the follow-up, he was prescribed a combination of levodopa and carbidopa. He remained stable without any relapse of symptoms of depression and PD for the next six months. DISCUSSION This case series demonstrates the beneficial effects that ECT can have in patients with comorbid depressionand PD. The beneficial effect of ECT on symptoms of PD were reported as early as 1947 by Gallinek. 5 In a review of literature published in 1991, the authors reported that ECT showed benefit in patients with movement disorders, irrespective of the presence of psychiatric comorbidity. There are 35 case reports on use of ECT in patients with PD. In six of the cases, patients with PD did not have comorbid psychiatric disorder. 9 ECT has also been shown to have positive effects on patients with drug-induced Parkinsonism, tardive dystonia, and tardive dyskinesia. Another review of literature from 1990 to 2000 reported 21 cases of ECT in patients with PD, as well as four additional reports on use of ECT in patients with parkinsonian symptoms. 10 The four reports included 135 patients, with motor scores being available for 76 patients to determine the efficacy of ECT. When combining information from the previous review, 9 the authors had information on 213 patients total. 10 Most of the reports (17 out of 25) published during the evaluation period were case reports and series, but there were two retrospective studies and four prospective open-label studies. 10 Eighty-eight percent (36 out of 41) of patients with PD who received ECT in the absence of a comorbid psychiatric disorder were reported to show improvement in motor symptoms. Among those with psychiatric disorders, 77 percent (58 out of 75) were reported to show improvement following ECT. 10 The six patients from our clinic showed improvement in both depressive and motoric symptoms followoing ECT. In terms of PD, although there is lot of inconsistency in reporting, there is evidence to suggest that ECT offers a beneficial effect on tremors, on/off time, rigidity, and cogwheeling. Our six patients showed improvement in tremors and rigidity. In terms of predictors of treatment response, some of the reports we reviewed suggest that a lower level of pre- existing impairment is associated with better response to ECT, whereas others suggest that a higher severity of symptoms and older age are associated with better response in motor symptoms. 10 In terms of severity, our six patients had severe PD symptoms prior to starting ECT. In terms of complications with ECT in patients with PD, the literature shows that 44 percent have been reported to develop delirium, 10 and one study reported delirium in 85 percent of the patients. 11 This suggests that patients with PD have higher a risk of developing delirium while being treated with ECT. It is important to understand that underlying pathogenesis for delirium includes dopamine activation; hence, concomitant use of antiparkinsonian medications can also contribute to the development of delirium. However, the available studies do not discuss this issue in detail. None of our patients developed delirium. A recent review has been published that evaluates data on ECT use in patients with depression and comorbid PD. 7 The authors of this review located 43 articles—27 were individual patient case reports, 13 were case series describing 2 to 11 patients, two were retrospective chart reviews, and one was a retrospective case control study that included 19 patients. All of these articles were published between 1975 and 2015. All except for one of these articles had data from 115 patients with PD and depression and one patient with PD and mania. The majority (93.1%) of the patients described in the review article were reported as having improvement in depression. The reviewed studies reported that 83 percent of the patients perceived improvement in motor symptoms and depression following ECT, 15 percent reported no improvement in motoric symptoms despite improvement in depression, and two percent reported worsened motoric symptoms despite improvement in depression. 7 Based on the

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