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 27 ICNS Innovations in Clinical Neuroscience • January–February 2018 • Volume 15 • Number 1–2 available information, the authors of that review article proposed an algorithm for management of depression in patients with PD, suggesting ECT should be considered if the depression is severe or if there is a worsening of depression. They further suggested that cognitive testing should be done prior to starting an ECT course. If a patient experiences significant cognitive deficits during the course of ECT, increasing the time between sessions or reducing the amount of energy used during treatment should be considered. In terms of electrodes, the recommendations suggest that a right unilateral ECT should be started with an ultra-brief pulse width. Patients with pre-existing dementia should be prescribed cholinesterase inhibitors, which might act as protective agents for ECT-associated cognitive deficits. 7 One study compared the effect of ECT on patients with or without PD. Both study arms included 25 patients, and 56 percent of those with PD reported improvement in motoric symptoms, 40 percent reported no change, and four percent reported worsening symptoms. More than half (56%) of patients with PD experienced side effects, which was significantly higher than the 12 percent reported among patients without PD. 12 A recent open-label study included six patients with PD and depression and used a right unilateral brief pulse ECT. All of the patients reported improvement in both depressive and motoric symptoms without worsening of cognitive symptoms immediately after completion of ECT and at the one-month follow-up. ECT has also recently been reported to benefit patients with PD with refractory psychosis, 13 refractory anxiety, 14 severe obsessive- compulsive disorder, 15 drug-induced psychosis, 16,17 residual axial symptoms partially unresponsive to L-dopa, 18 and drug-included Parkinsonian symptoms. 19 Various mechanisms have been proposed for the effectiveness of ECT in the management of motoric symptoms in patients with PD. One of the proposed mechanisms suggests that improvement in symptoms of depression leads to improvement in motoric symptoms. In terms of neurotransmitter mechanisms, alteration of dopaminergic and gamma-aminobutyric acid systems have been proposed, but an exact mechanism is not yet well understood. 20 In terms the of long-term effects of ECT on PD symptoms, it isn't clear how long the improvement in PD symptoms last after discontinuing ECT. 7,8,21 Two of our patients showed worsening in motoric symptoms 3 to 4 months after discontinuing ECT. Some of the available data suggest that maintenance ECT can be used to sustain improvement in motoric symptoms. 22,23 Despite the reported evidence, ECT has not found its due place in treatment protocols and guidelines for management of PD. Most protocols do not even mention ECT as a treatment option. 8 Possible stigma associated with ECT likely precludes its use in these patients, especially those without psychiatric comorbidity. With newer and more established treatments, like deep brain stimulation (DBS), further research into ECT use in PD does not seem urgent to researchers. 24 To conclude, ECT appears to have a beneficial effect on motoric symptoms in patients with PD, especially those with comorbid psychiatric disorders. However, proper precautions must be taken to reduce the associated complications, and patients must be closely monitored while undergoing ECT. REFERENCES 1. Grover S, Somaiya M, Kumar S, Avasthi A. Psychiatric aspects of Parkinson's disease. J Neurosci Rural Pract. 2015;6(1):65–76. 2. Cummings JL. Depression and Parkinson's disease: a review. Am J Psychiatry. 1992;149(4):443–54. 3. Dooneief G, Mirabello E, Bell K, et al. An estimate of the incidence of depression in idiopathic Parkinson's disease. Arch Neurol. 1992;49(3):305–7. 4. Allain H, Schuck S, Mauduit N. Depression in Parkinson's disease. BMJ. 2000;320(7245):1287–8. 5. Borisovskaya A, Bryson WC, Buchholz J, et al. Electroconvulsive therapy for depression in Parkinson's disease: systematic review of evidence and recommendations. Neurodegener Dis Manag. 2016;6(2):161–76. 6. Popeo D, Kellner CH. ECT for Parkinson's disease. Med Hypotheses. 2009;73(4):468–9. 7. Fromm GH. Observation on the effects of electroshock treatment in patients with Parkinsonism. Bull Tulane Univ. 1959;18:71–3. 8. Lebensohn ZM, Jenkins RB. Improvement of Parkinsonism in depressed patients treated with ECT. Am J Psychiatry. 1975;132(3):283–5. 9. Faber R, Trimble MR. Electroconvulsive therapy in Parkinson's disease and other movement disorders. Mov Disord. 1991;6(4):293–303. 10. Kennedy R, Mittal D, O'Jile J. Electroconvulsive therapy in movement disorders: an update. J Neuropsychiatry Clin Neurosci. 2003;15(4):407–21. 11. Figiel GS. ECT and delirium in Parkinson's disease. Am J Psychiatry. 1992;149(12):1759; author reply -60. 12. Moellentine C, Rummans T, Ahlskog JE, et al. Effectiveness of ECT in patients with parkinsonism. J Neuropsychiatry Clin Neurosci. 1998;10(2):187–93. 13. Nishioka K, Tanaka R, Shimura H, et al. Quantitative evaluation of electroconvulsive therapy for Parkinson's disease with refractory psychiatric symptoms. J Neural Transm (Vienna). 2014;121(11):1405–10. 14. Marino L, Friedman JH. Letter to the editor: successful use of electroconvulsive therapy for refractory anxiety in Parkinson's disease. Int J Neurosci. 2013;123(1):70–1. 15. Gadit AM, Smigas T. Efficacy of ECT in severe obsessive-compulsive disorder with Parkinson's disease. BMJ Case Rep. 2012;2012. 16. Muralidharan K, Thimmaiah R, Chakraborty V, Jain S. Bifrontal ECT for drug-induced psychosis in Parkinson's disease. Indian J Psychiatry. 2011;53(2):156–8. 17. Ueda S, Koyama K, Okubo Y. Marked improvement of psychotic symptoms after electroconvulsive therapy in Parkinson disease. J ECT. 2010;26(2):111–5. 18. Pintor LP, Valldeoriola F, Fernandez-Egea E, et al. Use of electroconvulsive therapy in Parkinson disease with residual axial symptoms partially unresponsive to L-dopa: a pilot study. J ECT. 2012;28(2):87–91. 19. Sadananda SK, Holla B, Viswanath B, et al. Effectiveness of electroconvulsive therapy for drug-induced parkinsonism in the elderly. J ECT. 2013;29(1):e6–7. 20. Narang P, Glowacki A, Lippmann S. Electroconvulsive therapy intervention for Parkinson's disease. Innov Clin Neurosci. 2015;12(9–10):25–8. 21. Lieberman A. Depression in Parkinson's disease—a review. Acta Neurol Scand. 2006;113(1):1–8. 22. Balke LD, Varma A. A case of long-term maintenance ECT in a 78-year-old with depression and possible Parkinson's disease. CNS Spectr. 2007;12(5):325–6. 23. Shulman RB. Maintenance ECT in the treatment of PD. Therapy improves psychotic symptoms, physical function. Geriatrics. 2003;58(11):43–5. 24. Cunningham MG, Yadollahikhales G, Vitaliano G, van Horne C. Administration of electroconvulsive therapy for depression associated with deep brain stimulation in a patient with post-traumatic Parkinson's disease: a case study. BMC Psychiatry. 2016;16(1):399. ICNS

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