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Table of Contents
LETTER TO THE EDITOR
Year : 2021  |  Volume : 35  |  Issue : 4  |  Page : 210-211

The efficacy of electroconvulsive therapy in a patient with posttraumatic stress disorder and major depression: A case report


1 Department of General Psychiatry, Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, Kaohsiung, Taiwan
2 Department of General Psychiatry, Kaohsiung Municipal Kai-Syuan Psychiatric Hospital; Department of Psychiatry, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan

Date of Submission17-May-2021
Date of Decision21-Jul-2021
Date of Acceptance23-Jul-2021
Date of Web Publication21-Dec-2021

Correspondence Address:
M.D., Ph.D Ching- Hwa Lin
No. 130, Kai-Syuan Second Road, Ling-Ya District, Kaohsiung 802
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TPSY.TPSY_41_21

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How to cite this article:
Tsai TH, Shih YJ, Lin CH. The efficacy of electroconvulsive therapy in a patient with posttraumatic stress disorder and major depression: A case report. Taiwan J Psychiatry 2021;35:210-1

How to cite this URL:
Tsai TH, Shih YJ, Lin CH. The efficacy of electroconvulsive therapy in a patient with posttraumatic stress disorder and major depression: A case report. Taiwan J Psychiatry [serial online] 2021 [cited 2022 Aug 12];35:210-1. Available from: http://www.e-tjp.org/text.asp?2021/35/4/210/332970



A relatively high percentage of patients with posttraumatic stress disorder (PTSD) also has major depressive disorder (MDD) comorbidity, but the number varies according to different studies [1],[2],[3]. Selective serotonin reuptake inhibitors (SSRIs) are considered the first-line pharmacological treatment for both PTSD and MDD. Electroconvulsive therapy (ECT) should be considered if medication trials fail for MDD. In this case report, we present a 49-year-old male patient with comorbid PTSD and MDD. He showed substantial clinical improvement in both disorders after a course of nine treatments of bitemporal and modified ECT twice a week.


  Case Report Top


A 49-year-old male patient working as a truck driver had a life-threatening traffic accident. The truck tractor was almost completely deformed, fortunately sparing the driver's seat area, and the man was seriously but not fatally injured. He suffered from five broken ribs as well as cervical and lumbar spine compression injury.

A half of a year after the accident, the patient still suffered from intermittent low back pain. He received two surgeries to relieve the pain but in vain. Since then, he had gradually developed depressed mood, fatigue, feelings of guilt, and intrusion of thoughts, avoidance, and arousal symptoms, fulfilling the criteria for both PTSD and MDD according to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) criteria. He was hospitalized on our psychiatry ward after several suicidal attempts. He did not respond to initial drug treatment. After failing at least two trials of two antidepressants (sertraline 50 mg/day and duloxetine 60 mg/day over six weeks each), he agreed to receive ECT. All psychotropic medications were discontinued before ECT except anxiolytic or sedative-hypnotic agent use as needed.

The patient's condition was assessed using clinician-administered PTSD scale for DSM-5 (CAPS-5) [4], Hamilton Depression Rating Scale-17 (HAMD-17), and Udvalg for Kliniske Unders gelser (UKU) side effect rating scale [5]. Higher total scores reflect higher severity of symptoms. [Figure 1] shows the changes of CAPS-5 (upper panel) and HAMD-17 (lower panel) being rated at baseline, after every three ECT sessions, and after the final ECT session. CAPS-5 was rated by THT (the first author); HAMD-17 and UKU side effect rating scale were rated by CHL (the corresponding author). PTSD was no longer present and MDD had achieved partial remission by the time ECT was completed. Regarding the intrusive symptoms of PTSD, the severity of intrusive memories and distressing dreams showed a marked decline from the baseline rating to the final rating. Intrusive memories score went from 3 (severe) to 1 (mild); distressing dreams score went from 2 (moderate) to 0 (absent). As for subjective memory side effects of ECT, item 1–4 (failing memory) of the UKU side effect rating scale showed a score from 1 (present to a mild degree) at baseline to 0 (not or doubtfully present) at the final rating. But retrograde amnesia was not assessed using standard neuropsychological examinations. Between the 7th and the 8th ECT session, the patient asked for a hypnotic agent for three consecutive nights. Brotizolam 0.25 mg was given on the first night; estazolam 2 mg was given on the second and third night. Sleep quality and quantity were subjectively acceptable after as needed medication administration.
Figure 1: CAPS-5 scores (upper panel) and HAM-D scores (lower panel) before and after 3, 6, and 9 sessions of electroconvulsive therapy. After a course of ECT sessions, CAPS-5 scores were changed from 39 to 7 and HAMD-17 scores from 31 to 1. ECT, electroconvulsive therapy; CAPS-5, clinician-administered PTSD scale for DSM-5; HAMD-17, 17-item Hamilton Depression Rating Scale.

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  Comment Top


In this patient, ECT was associated with a marked reduction of both PTSD and MDD symptoms. According to the current literature, ECT induces hippocampal neurogenesis, in turn improving PTSD symptoms [6]. Some studies also showed that ECT improves both PTSD and MDD symptoms. For example, Helsley et al. [7] reported that a 35-year-old woman received ECT for PTSD and depression, and that a great improvement of her depression and recurrent intrusive thoughts is reported after the third treatment session. Watts [8] conducted a retrospective review of 26 MDD patients with co-occurring PTSD who received a course of ECT. Those receiving ECT have a remarkable reduction in the symptoms of depression and some amelioration in PTSD symptoms. Ahmadi et al. [9] conducted a retrospective case–control study, in which ECT is associated with a remarkable reduction of symptoms of PTSD and MDD, as well as reduction in risk of suicidality, cardiovascular, and all-cause mortality, compared with antidepressant therapy only. Ahmadi et al. [10] later conducted a retrospective study on maintenance ECT on patients with MDD with and without comorbid PTSD and concluded that maintenance ECT is associated with reduction of both MDD and PTSD symptoms and a favorable clinical outcome.

The literature mentioned above mostly are focused on subjects with comorbid MDD and PTSD. A recent systematic literature review from 1958 through 2016 examined the efficacy of ECT in improving PTSD symptoms, and concluded that current efficacy data do not support an effect of ECT on PTSD symptoms independent of that on depression [11]. Randomized controlled trials are necessary to examine the use of ECT in medication-refractory PTSD patients with and without comorbid depression.

In summary, ECT had a powerful positive immediate effect on the MDD symptoms and PTSD symptoms in our patient. Whether this positive effect will last in the long-term will require further follow-up and assessment. Based on findings of previous studies, maintenance ECT may also be potentially effective and may be considered as a future treatment option. (This study was approved for publication by the institutional review board of Kaohsiung Municipal Kai-Syuan Psychiatric Hospital (protocol number = KSPH-2021-09 and date of approval = May 12, 2021) with the requirement of obtaining a signed information consent from the patient).


  Financial Support and Sponsorship Top


None.


  Conflicts of Interest Top


The authors declare no conflicts of interest in writing this case report.



 
  References Top

1.
Caramanica K, Brackbill RM, Liao T, et al.: Comorbidity of 9/11-related PTSD and depression in the World Trade Center Health Registry 10-11 years postdisaster. J Trauma Stress 2014; 27: 680-8.  Back to cited text no. 1
    
2.
Kessler RC, Sonnega A, Bromet E, et al.: Posttraumatic stress disorder in the national comorbidity survey. Arch Gen Psychiatry 1995; 52: 1048-60.  Back to cited text no. 2
    
3.
Rytwinski NK, Scur MD, Feeny NC, et al.: The co-occurrence of major depressive disorder among individuals with posttraumatic stress disorder: A meta-analysis. J Trauma Stress 2013; 26: 299-309.  Back to cited text no. 3
    
4.
Weathers FW, Blake DD, Schnurr P, et al.: The Clinician-Administered PTSD Scale for DSM-5 (CAPS-5). Boston: National Center for Posttraumatic Stress Disorder, 2013.  Back to cited text no. 4
    
5.
Lingjaerde O, Ahlfors UG, Bech P, et al.: The UKU side effect rating scale. A new comprehensive rating scale for psychotropic drugs and a cross-sectional study of side effects in neuroleptic-treated patients. Acta Psychiatr Scand Suppl 1987; 334: 1-100.  Back to cited text no. 5
    
6.
Bouckaert F, Sienaert P, Obbels J, et al.: ECT: its brain enabling effects: a review of electroconvulsive therapy-induced structural brain plasticity. J ECT 2014; 30: 143-51.  Back to cited text no. 6
    
7.
Helsley S, Sheikh T, Kim KY, et al.: ECT therapy in PTSD. Am J Psychiatry 1999; 156: 494-5.  Back to cited text no. 7
    
8.
Watts BV: Electroconvulsive therapy for comorbid major depressive disorder and posttraumatic stress disorder. J ECT 2007; 23: 93-5.  Back to cited text no. 8
    
9.
Ahmadi N, Moss L, Simon E, et al.: Efficacy and long-term clinical outcome of comorbid posttraumatic stress disorder and major depressive disorder after electroconvulsive therapy. Depress Anxiety 2016; 33: 640-7.  Back to cited text no. 9
    
10.
Ahmadi N, Moss L, Hauser P, et al.: Clinical outcome of maintenance electroconvulsive therapy in comorbid posttraumatic stress disorder and major depressive disorder. J Psychiatr Res 2018; 105: 132-6.  Back to cited text no. 10
    
11.
Youssef NA, McCall WV, Andrade C: The role of ECT in posttraumatic stress disorder: a systematic review. Ann Clin Psychiatry 2017; 29: 62-70.  Back to cited text no. 11
    


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