To the Editor: Primary indications for ECT include major depression, mania, and psychosis. ECT may be indicated in the treatment of affective disorders associated with medical illness (1). The APA Task Force on ECT lists space-occupying cerebral lesions under "Situations Associated With Substantial Risk" for ECT; however, there are several case studies on the efficacy of ECT in treating depression in such situations (2). We present the case of a woman with treatment-resistant depression associated with a recurrent brain tumor who experienced rapid remission of her symptoms after ECT.
Ms. A was a 35-year-old woman whose medical history was notable for a left-frontal neurocytoma, two subsequent incomplete resections, and radiation treatment. The neurocytoma was detected during a routine workup for the acute onset of depression. Neurocytomas are a rare, slow-growing type of brain tumor with a high rate of recurrence. Ms. A’s subsequent psychiatric illness course was characterized by recurrent hospitalizations for persistent dysphoria, apathy, and hopelessness, including six hospitalizations within 18 months. Trials with more than 10 tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), and non-SSRIs produced no definite improvement, while methylphenidate and lorazepam produced transient improvement in her behavior.
Ms. A had been transferred from another hospital, in which she had been hospitalized for 6 weeks after admission for depression and multiple suicide attempts by drowning. After admission to our neuropsychiatry unit, Ms. A remained reclusive, was frequently tearful, stared aimlessly for long periods, and was absent of, or had greatly delayed, verbal and motoric responses. She experienced somatic and religious delusions and expressed a wish to die. The results of a neurological examination revealed mild right-sided weakness and mild transcortical motor aphasia. ECT was considered because of the lack of adequate antidepressant response and increasing suicidality. An ECT workup, including magnetic resonance imaging of Ms. A’s brain, revealed a large, complex mass in the left lateral ventricle and left frontal encephalomalacia. A thallium brain scan revealed left frontal hypovascularity but no evidence of tumor recurrence; an EEG showed left hemispheric slowing but no epileptiform activity.
Within 6 hours after right unilateral ECT, Ms. A appeared bright, had improved speech and motoric response, and recalled feeling "bad" and wanting to hurt herself before treatment. Two additional ECT treatments produced full resolution of her dysphoria, hypomotoric state, and delusions. After discharge and withdrawal of antidepressants, Ms. A’s mood remained stable over the next 8 months to the point that she pursued a job and driving privileges.
For this patient, who suffered from medication-resistant depression and akinesia secondary to a static brain tumor, ECT proved to be beneficial and without side effects. Unlike in previous cases, our patient experienced a rapid and prolonged antidepressant response and her brain tumor was not a coincidental condition.