Electroconvulsive therapy for psychosis in a patient with a traumatic brain injury

To the Editor

Spiers et al. (2016) reported improvement in psychosis in a patient with traumatic brain injury (TBI) following a seizure in the December 2016 Australian & New Zealand Journal of Psychiatry (ANZJP). They asserted that there are no reports of the use of electroconvulsive therapy (ECT) in patients with TBI and psychosis. Upon searching the literature using the Medline database, we found case reports of patients with TBI being given ECT (and responding well) for non-psychosis reasons, but not for psychosis.

We report a case of a 17-year-old male with a TBI who was admitted for treatment of psychosis. As a toddler he was involved in an accident resulting in left-sided head and chest injuries. This caused mild speech and cognitive impairments as well as significant anxiety as a child. At age 14, he began smoking cannabis and by age 16 began experiencing psychotic symptoms including persecutory beliefs and thought broadcasting. He was initially treated in the community with olanzapine, which had good effect with most of his symptoms resolving. He resumed smoking cannabis and was non-compliant with medications resulting in a relapse of symptoms, including significant thought disorder, paranoid thoughts, auditory hallucinations and aggression towards his family.

He was admitted to hospital and restarted on olanzapine with good early response, but had ongoing auditory hallucinations and mild thought disorder, thus the olanzapine dose was increased. His symptoms did not improve and within a short period of time he became increasingly paranoid about staff and co-patients resulting in agitation and aggression requiring seclusion, transfer to the high-dependency unit and emergency ECT. Following four treatments of right-unilateral ECT his psychotic symptoms resolved and he was no longer demonstrating any agitation.