(091) ECT in the General Hospital: A New Challenge for C-L Psychiatry Teams? Review of Three Patients Treated at the ICU

Background/Significance:
Electroconvulsive therapy (ECT) has been shown to be an effective and safe treatment for catatonic symptoms, including catatonia due to general medical conditions. However, there is still a lack of clinical reports of ECT treatment in patients with malignant catatonia or neuroleptic induced catatonia in intensive care units. Furthermore, the use of ECT in patients suffering from persistent delirium is still controversial, despite some clinical reports showing its effectivity and safety where the treatment as usual has failed. In order to review and discuss the importance of counting with an ECT team in the general hospital, we summarize the clinical experience of three ICU patients treated with ECT.

Methods:
Three consecutive SARS-COV-2 pneumonia patients with prolonged delirium that developed catatonic symptoms and did not respond to the usual treatment were included in this report.

Results:
Two cases of both adults 36-year-old and 58-year-old male without prior psychiatric or medical history, admitted due to acute respiratory failure in the context of SARS-Cov-2 pneumonia. The patients developed several infectious intercurrent complications, presenting persistent hyperactive delirium with catatonic symptoms associated with malignant features that were resistant to treatment as usual. Bitemporal ECT was tried, with complete remission of delirium and catatonic symptoms after 4 sessions.

One case of 62 year old male patient with current major depression disorder with psychotic features in partial remission, was admitted due to acute respiratory failure in the context of SAR-Cov-2 pneumonia. The patient presented hyperactive delirium, and developing catatonic symptoms. Bitemporal ECT was tried, achieving full remission of agitation and catatonic symptoms after 10 sessions.

Discussion:
Prolonged delirium with catatonic symptoms is associated with major mortality, cognitive impairment and other morbidities. Therefore, CL Psychiatrists should be aware and able to implement measures for early treatment, and this includes the expedited access to ECT in the general hospital.

Conclusion/Implications:
ECT is a highly effective intervention for patients with prolonged delirium associated to catatonic symptoms where the usual treatment failed. The collaborative work of CL Psychiatrist in the ICU should favor the use of ECT in patients where delirium and catatonia are present. Given the higher rates of delirium due to medical circumstances in ICU but also higher awareness (and diagnosis), the possibility of delivering ECT as part of the CL psychiatric team standard care seems all the more promising and fundamental.

References:
1) Dessens FM, van Paassen J, van Westerloo DJ, van der Wee NJ, van Vliet IM, van Noorden MS. Electroconvulsive therapy in the intensive care unit for the treatment of catatonia: a case series and review of the literature. Gen Hosp Psychiatry. 2016;38:37-41.
2) Braithwaite R. Successful electroconvulsive therapy in a patient with confirmed, symptomatic covid-19. 2020.
3) Lupke K, Warren N, Teodorczuk A, et al. A systematic review of modified Electroconvulsive Therapy (ECT) to treat delirium. Acta Psychiatr Scand. August 2022.
4) Nielsen RM, Olsen KS, Lauritsen AO, Boesen HC. Electroconvulsive therapy as a treatment for protracted refractory delirium in the intensive care unit—Five cases and a review. J Crit Care. 2014;29(5):881.e1-881.e6.