Suggested Protocol for Electroconvulsive Therapy for Depression in a Parkinson's Disease Patient with a Deep Brain Stimulator: A Case Report

Introduction: We report one a case of bilateral electroconvulsive therapy (ECT) conjointly done in a patient with a deep brain stimulator (DBS) in place for Parkinson's disease (PD), to show that it can be accomplished safely and effectively. DBS is a nonsurgical treatment used to improve unwanted involuntary movement in PD and other movement disorders. Through intracranial electrodes it delivers electrical impulse to the globus pallidus, subthalamic nucleus (STN) or thalamus, inhibiting unwanted movement. Depression occurs in approximately 40% of patients with PD. There is currently limited data available on the use of ECT in the presence of the DBS. Case: 48 yo Hispanic Male with history of severe depression as well as severe PD diagnosed for over 10 years. A DBS was placed in 2010 in bilateral STN, and the device allowed him to remain relatively asymptomatic together with Requip, Sinemet and Selegiline. 5 years after DBS implantation he presented to our hospital, in May 2015, with severe depression, thoughts of suicide, hallucinations and daily alcohol use. In consultation with Neurology, geriatric psychiatry and patient's primary psychiatric team, it was deemed that patient was suitable for ECT treatment. He was started on ECT treatment with very positive results. Has been able to tolerate going off Sinemet and Selegiline with maintenance of his functionality and relatively asymptomatic from PD, as well as with improvement on his mood. Methods: A literature review had been thoroughly conducted by the primary psychiatry treatment team, the Geriatric Specialist, and the ECT treatment team. Additionally, access to Journal of ECT listserv had led to communication with other physicians with prior published case studies on DBS patients with good response to ECT. Based on current literature review, discussion with Neurology, and with consulting MDs on listserv, it was recommended to proceed with bitemporal electrode placement to have greatest distance from patient's frontoparietal DBS insertion points. We used the Thymatron IV System, and a stimulus of 15% of maximum charge and 0.5 PW was utilized based on evidence published in Clinical Manual of Electroconvulsive Therapy by Mehul Mankad, M. D, et. al. related to known seizure thresholds and to ensure adequate dosing in a male BL patient. Patient did not have a seizure and there was no published data on re-stimulation so we aborted the treatment. We increased the stimulus to 25% on the next treatment and patient again did not have a seizure. The stimulus parameter was doubled for the next treatment as repeated stimuli without treatments was putting the patient at risk of complications without any added benefit. On treatment #3 with a stimulus of 50% the patient had a good quality seizure lasting 50 seconds on EEG and a motor seizure of 29 seconds. Over the next 3 months the stimulus was gradually increased to 100% and his last seizure lasted 51 seconds on EEG . This was the patient's 13th treatment and only 11th seizure. Results: ECT was effectively and safely utilized to treat the patient's depression as well as psychosis without harming the patient or damaging the DBS hardware. A Montgomery Asberg Depression Rating Scale (MADRS), Spanish version, was done on a weekly basis to assess improvements on mood. The first MADRS performed on 5/22/15 was 47. By treatment #11 and seizure # 9 the MADRS score had decreased to 8. The patient received a total of 13 treatments. The patient's Parkinson's symptoms also decreased and he required less medication upon discharge from the hospital. Conclusions: As DBS are becoming more commonplace as a therapeutic treatment for patient's with PD it is becoming increasingly imperative that we understand and adapt to a changing field. Depression and PD is well documented, as is the relationship between DBS placement in STN and an increase risk of mood disorders. It is our goal is to add to the growing body of evidence about the safety and efficacy of ECT in patients with DBS as well as provide a suggested protocol for treatments. The technique herein described may be applicable to other patients who have co morbid PD with DBS such as the geriatric population. Age is the single most consistent risk factor for PD and with the increasing age of the general population the prevalence of PD with its complications such as depression will rise in the future.