Electroconvulsive therapy in an adolescent with major depressive disorder and pre-existing arrhythmogenic right ventricular cardiomyopathy

Dear Editor,

Major depressive disorder (MDD) is common in adolescents with a lifetime prevalence of 11% in the US.¹ Suicide is the second leading cause of death between ages 10–19, and 8% of high school students reported a suicide attempt in the prior year. To add to this concern, we have seen a disproportionate increase of suicide rates in females relative to males amid the ongoing crisis of suicide rates in adolescents which has been steadily rising since 2007.² Given that 40% of adolescents will fail to respond to first-line antidepressants, avenues of rapid improvement are a necessary consideration, and those with severe symptoms may require rapid treatment with electroconvulsive therapy (ECT).³ Despite efficacy, there is a paucity of literature describing ECT use in adolescents with cardiac conditions which can present additional concerns towards anesthesia among parents or treatment teams. We present an adolescent with MDD and arrhythmogenic right ventricular cardiomyopathy (ARVC) successfully and safely treated with ECT.

Case Report

Ms. A was a 15-year-old female with ARVC and anorexia nervosa referred for MDD management. When she was 6-years-old, her 14-year-old brother died from sudden cardiac arrest. Autopsy demonstrated that he had ARVC, and a DSG-2 (a gene encoding desmoglein 2, a calcium-binding transmembrane glycoprotein of myocardial desmosomes) mutation. Cardiac mortality in patients with ARVC is thought to be less than 5%, with the most likely cause being sudden ventricular arrhythmia.⁴

At 11-years-old, Ms. A was found to have the same DSG-2 mutation. EKGs demonstrated normal sinus rhythm with right bundle branch block, T-wave inversions in the anteroseptal leads, and a borderline QT interval. Echocardiogram and cardiac MRI showed a dilated right ventricle with mild-to-moderate tricuspid regurgitation, areas of dyskinesia in the right ventricle, thinning in multiple areas of left ventricle, and a reduced ejection fraction of 29% and 52% in the right and left ventricles, respectively. Ms. A was initially maintained on metoprolol 25 mg twice daily and Lisinopril 10 mg daily with continued monitoring. At 14-years-old, an automatic implantable cardiac defibrillator (ICD) was implanted due to progressive phenotype demonstrated by cardiac MRI coupled with increased ventricular ectopy.

After ICD placement, Ms. A began having depressive symptoms, leading to two psychiatric hospitalizations within the same year. This included a suicide attempt via a significant diphenhydramine overdose. Outpatient management included: fluoxetine 40mg daily, aripiprazole 2mgd daily, and dialectal behavioral therapy (DBT). She was hospitalized a third time for intentional ibuprofen overdose and referred to ECT for treatment resistant depression and suicidal ideation. Her mental status exam was notable for psychomotor slowing, guardedness, flat affect, and suicidal ideation. She scored 17 on the Quick Inventory of Depressive Symptomatology -Self Report (QIDS) (severe symptoms).

Unique to Ms. A’s case was her increased cardiac risk related to ARVC and anesthesia. There were no studies examining risks of pediatric patients with cardiac conditions in the literature. Duma and colleagues found that in a population of 106,569 adult patients receiving ECT, the all-cause mortality rate was 0.04%. 29% of deaths were attributed to cardiac events, and approximately 2% of patients had lethal or non-lethal major cardiac events, defined as myocardial infarction, pulmonary edema, pulmonary embolism, acute heart failure, arrhythmia, and cardiac arrest. A sub-analysis evaluating effects of preexisting cardiac illness on risk did not yield statistically significant outcomes.⁵ With these considerations and via consultation with cardiac electrophysiology, ECT consultants, anesthesiology, it was deemed that the benefits of ECT outweighed Ms. A’s cardiac risks. Her parents assented to ECT, and the ECT petition was approved by the mental health court, in accordance with Missouri state law for minors.

ECT treatments began thrice weekly. Cardiac electrophysiologists recommended magnet placement over the ICD to deactivate the device and reduce the need for multiple reprogramming with each treatment. Routine ICD checks were performed throughout ECT therapy to ensure lead integrity. Initial treatment was a right unilateral titration using a Thymatron IV, Somatics, LLC device (Lake Bluff, IL) with settings of 5% charge, 0.3 ms pulsewidth, 10 Hz frequency which produced a prolonged central seizure of 204 seconds terminated with propofol 30 mg IV. Subsequent treatments were administered at six-fold charge with subsequent increase to maximum settings at 100% charge (0.3 ms pulsewidth; 120 Hz frequency) to achieve remission. Etomidate 12 mg and succinylcholine 40–50 mg were used for induction and muscle relaxation.

Ms. A’s depression improved rapidly, and she was considered safe for hospital discharge after her third ECT treatment. Figure 1 displays Ms. A’s ECT course. Remission (QIDs ≤ 5 consecutively) was obtained by the 13^th treatment. ECT was tapered to twice weekly, then weekly while maintaining response. ECT taper was slowed due to increases in QIDS associated with longer intervals between treatments. A total of 38 index and maintenance treatments occurred.

Figure 1. Quick Inventory of Depressive Symptomatology (QIDS) scores throughout ECT course.

Each point represents an ECT treatment. QIDS scores were collected before each ECT session. Treatment response was defined as an equal to or greater than 50% reduction in initial QIDS score. Remission was defined as QIDS less than or equal to 5 over three consecutive treatments. Zones are numbered on top of the chart and represent ECT frequency. Zone 1 represents ECT frequency of 2–3 times per week; zone 2 represents frequency of once per week; zone 3 represents frequency of once every other week; zone 4 represents frequency of once every 3–4 weeks.

Ms. A had a remarkable improvement in depression. She returned to school where she earned excellent grades on a full course load and extracurriculars, began reengaging with hobbies (e.g., Bible study), and socialized with friends. Ms. A did experience side effects hypotension immediately post-ECT, headache, and prolonged seizure (>180 seconds). Ketorolac 15 mg IV and sumatriptan 6 mg IV were given prophylactically to attenuate headaches. Lisinopril was held the day prior to ECT to prevent hypotension. Regarding cognitive side effects, Ms. A reported subjective concerns with processing speed, word finding, and episodic memory during the acute ECT series. Although Ms. A had not undergone baseline neuropsychological testing prior to ECT, she received neuropsychological testing during maintenance treatments which demonstrated that overall intellectual ability, verbal reasoning, language, perceptual and nonverbal reasoning, and visual-spatial skills were intact.

Conclusion

This adolescent with MDD and ARVC managed with an ICD was safely and effectively treated with ECT. Ms. A’s preexisting cardiac pathology was weighed against her debilitating depression with persistent suicidal ideation and self-harm. Ms. A experienced no significant cardiac side effects during treatment course. This report adds to the literature and the safety profile of ECT, as there is currently no previous report of an adolescent with a cardiac condition.