Psychosis after electroconvulsive therapy in a depressed patient

To the Editor

Electroconvulsive therapy (ECT) is an important treatment option in treatment-resistant major depression. Known adverse effects comprise cognitive impairments, amnesia, headaches and post-ECT delirium (Andrade et al., 2016). Psychotic symptoms after ECT have been reported once in a 79-year-old man (Zwil and Pomerantz, 1997). We present here a young depressive but otherwise healthy patient developing psychotic symptoms after ECT.

A 38-year-old Caucasian woman with a 10-year history of major depression was admitted with the third depressive episode showing depressed mood, lack of energy and interest, and disturbances of concentration, sleep and appetite (Hamilton Depression Rating Scale [HDRS-17] total score 36). She had a family history of depression. There was neither an individual nor family history of psychotic or manic symptoms and no current non-psychiatric disorders. Two-week treatment with escitalopram was ineffective. We switched to venlafaxine showing an antidepressant effect at 225 mg/day but also an intolerable elevation of blood pressure (150/100 mmHg). We established a combination therapy with sertraline (100 mg/day) and mirtazapine (30 mg/day), again without improvement. The patient declined lithium augmentation but agreed to ECT. During a series of 12 ECT sessions (2–3/week) and continuing the last medication, depressive symptoms remitted within 4 weeks. There were no adverse effects besides headaches and tiredness. The patient, still remitted and otherwise healthy, received a single maintenance ECT 14 days later. As before, alfentanil, propofol and succinylcholine were used for anesthesia. The seizure lasted slightly longer than during previous ECT sessions (55 instead of 30-40 seconds). After ECT, the patient was quickly oriented and coherent. The day after ECT, however, she developed delusions of reference, formal thought disorders, psychomotor agitation and emotional distress. Since the symptoms persisted for over 24 hours, we began treatment with risperidone 2 mg/day. Psychotic symptoms remitted within 4 days, so we discontinued risperidone. However, the psychotic symptoms relapsed within 2 days but remitted again after risperidone 4 mg/day.

ECT induces generalized seizures resembling epileptic seizures. Postictal psychosis is a phenomenon well known in epilepsy (Hilger et al., 2016). Interestingly, there is only one description of postictal psychosis after ECT so far (Zwil and Pomerantz, 1997). In that case, however, the patient already had psychotic symptoms pre-ECT and had experienced post-ECT delirium in the past. The patient presented here is young, otherwise healthy and had no prior psychotic symptoms or delirium. This case might make clinicians aware that post-ECT psychosis may occur in depressed patients who are otherwise healthy.