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Efficacy of Electroconvulsive Therapy for the Treatment of Movement Disorders: A Literature Review. Cureus 2023; 15:e36634. [PMID: 36968685 PMCID: PMC10038173 DOI: 10.7759/cureus.36634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2023] [Indexed: 03/26/2023] Open
Abstract
Electroconvulsive therapy (ECT) is a safe and effective treatment modality for various psychiatric disorders. However, evidence suggests a putative role of ECT in treating movement disorders that are refractory to less invasive modalities. ECT is primarily used in treatment-resistant psychiatric disorders. However, growing evidence exists for its use in movement disorders with and without psychiatric comorbidity. The primary objective of this systematic review was to examine the efficacy of ECT as a primary treatment modality for movement disorders. Relevant, peer-reviewed publications were retrieved from PubMed, SCOPUS, CINAHL, and PsycINFO. Keywords related to ECT and movement disorders were used as search phrases to identify relevant articles. A total of 90 articles that met the inclusion criteria were included in this review. Core findings were subsequently appraised on the role of ECT in treating movement disorders. Inclusion and exclusion criteria were developed to guide the search and selection process. Sources that met the inclusion criteria were those published between 2001 and January 2023. Additionally, peer-reviewed journals published in the English language covering the role of ECT in movement disorders were deemed appropriate for inclusion. Sources published before 2001, written in a non-English language, and not from peer-reviewed journals were excluded from this systematic review. The exclusion criteria also entailed eliminating duplicates from the review list. Most reviewed sources revealed that ECT improved outcomes in symptoms associated with various movement symptoms. However, ECT does not have a long-lasting impact on neuroacanthocytosis symptoms. Additionally, ECT is negatively associated with aggression and agitation, two of the most critical movement symptoms of Alzheimer’s disease. Evidence affirms the efficacy of ECT in providing symptomatic relief for movement disorders aside from psychiatric comorbidities. This positive association highlights the need for randomized controlled studies to identify movement disorder sub-populations that may respond to ECT.
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Jaimes-Albornoz W, Ruiz de Pellon-Santamaria A, Nizama-Vía A, Isetta M, Albajar I, Serra-Mestres J. Catatonia in older adults: A systematic review. World J Psychiatry 2022; 12:348-367. [PMID: 35317341 PMCID: PMC8900590 DOI: 10.5498/wjp.v12.i2.348] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 07/27/2021] [Accepted: 01/20/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Catatonia is a complex psychomotor syndrome that often goes unrecognized and untreated, even though its classification has evolved in recent years. Prompt and correct identification of catatonia allows for highly effective treatment and prevention of possible complications. The underrecognition of catatonia in older patients is also frequent, and research in this population is scarce.
AIM To conduct a systematic review of the literature on catatonia in older people to ascertain its clinical characteristics across settings.
METHODS Following the PRISMA guidelines, MEDLINE, EMBASE, and PsycINFO databases were searched from inception to December 2021, with a strategy aimed at identifying all articles published on catatonia in older adults. Titles and abstracts were scanned and selected independently by two authors. Papers investigating issues related to catatonia and/or catatonic symptoms in older people, with English abstracts available, were included. References of selected articles were revised to identify other relevant studies.
RESULTS In total, 1355 articles were retrieved. After removing duplicates, 879 remained. Of the 879 identified abstracts, 669 were excluded because they did not meet the inclusion criteria. A total of 210 articles underwent full text review, and 51 were eliminated for various reasons. Fourteen more articles were selected from the references. Overall, 173 articles were reviewed: 108 case reports, 35 case series, 11 prospective cohort studies, 6 case-control studies, 3 retrospective cohort studies and 10 reviews. We found several particular aspects of catatonia in this population. Catatonia in older patients is highly prevalent and tends to have a multifactorial etiology. Older patients, compared to younger patients, have a higher risk of developing catatonia with benzodiazepine (BZD) withdrawal, in bipolar disorder, and in the general hospital. Age, together with other risk factors, was significantly associated with the incidence of deep venous thrombosis, neuroleptic malignant syndrome poor outcome, other complications and mortality. Treatment with BZDs and electroconvulsive therapy is safe and effective. Prompt treatment of its cause is essential to ensure a good prognosis.
CONCLUSION Catatonia in older patients is highly prevalent and tends to have a multifactorial etiology. The risk of developing catatonia in some settings and conditions, as well as of developing complications, is high in this population. Symptomatic treatment is safe and effective, and timely etiologic treatment is fundamental.
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Affiliation(s)
- Walter Jaimes-Albornoz
- Psychiatry Service, Hospital Universitario Donostia, Basque Health Service - Osakidetza, San Sebastian 20014, Gipuzkoa, Spain
| | - Angel Ruiz de Pellon-Santamaria
- Psychiatry Service, Hospital Universitario Donostia, Basque Health Service - Osakidetza, San Sebastian 20014, Gipuzkoa, Spain
| | - Ayar Nizama-Vía
- Psychiatry Service “Virgen del Cisne” Mental Health Community Center, Regional Health Directorate, Tumbes 24002, Peru
| | - Marco Isetta
- Library and Knowledge Services, Central & North West London NHS Foundation Trust, St Charles’ Hospital, London W10 6DZ, United Kingdom
| | - Ines Albajar
- Neurology Service, Hospital Universitario Donostia, Basque Health Service - Osakidetza, San Sebastian 20014, Gipuzkoa, Spain
| | - Jordi Serra-Mestres
- Old Age Psychiatry Service, Cardinal Clinic, Windsor SL4 5UL, United Kingdom
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Jaimes-Albornoz W, Ruiz de Pellon-Santamaria A, Nizama-Vía A, Isetta M, Albajar I, Serra-Mestres J. Catatonia in older adults: A systematic review. World J Psychiatry 2022; 12:359-381. [DOI: 10.5498/wjp.v12.i2.359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Tripodi B, Barbuti M, Novi M, Salarpi G, Fazzari G, Medda P, Perugi G. Clinical features and predictors of non-response in severe catatonic patients treated with electroconvulsive therapy. Int J Psychiatry Clin Pract 2021; 25:299-306. [PMID: 34382488 DOI: 10.1080/13651501.2021.1951294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To explore the demographic and clinical features of severe catatonic patients, comparing responders and non-responders to ECT in order to detect possible predictors of non-response. METHODS This naturalistic study included 59 catatonic inpatients with a diagnosis of mood disorder according to DSM-IV-TR criteria. All patients were treated with bilateral ECT and evaluated before and after ECT course. The response to ECT was defined as a Clinical Global Impression (Improvement subscale) rating 1 'very much improved' or 2 'much improved'. Clinical variables were compared between responders and non-responders; logistic regression was used to predict the probability of non-response, with regard to the symptoms presented by the patients. RESULTS The response rate was 83.1%. Non-responders (n = 10) to ECT showed neurological comorbidities, treatments with dopamine agonists and anticholinergic drugs, waxy flexibility, and echophenomena more frequently than respondents (n = 49). Echophenomena resulted a significant predictor of non-response in the multivariate analysis. CONCLUSION In line with previous reports, ECT resulted effective in the vast majority of severe catatonic patients. The association between ECT resistant catatonia and neurological comorbidity, use of dopamine-agonist and anticholinergic medications is consistent with the hypothesis that ECT is more effective in 'top-down' than in 'bottom-up' variant of catatonia.Key pointsCatatonic symptoms are frequently associated with severe and psychotic mood disorders.Electroconvulsive therapy is effective in treating most forms of severe catatonia.Neurological comorbidity and the presence of 'echopraxia/echolalia' could represent predictors of non-response to ECT.
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Affiliation(s)
- Beniamino Tripodi
- Psychiatry Unit 2, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Margherita Barbuti
- Psychiatry Unit 2, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Martina Novi
- Psychiatry Unit 2, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Gianluca Salarpi
- Psychiatry Unit 2, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Giuseppe Fazzari
- Psychiatry Unit n.23 di Montichiari - Brescia, Azienda Spedali Civili di Brescia, Brescia, Italy
| | - Pierpaolo Medda
- Psychiatry 2 Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Giulio Perugi
- Psychiatry Unit 2, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.,Psychiatry 2 Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
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Saito Y, Noto K, Kobayashi R, Suzuki A, Morioka D, Hayashi H, Otani K. Catatonia as the Initial Manifestation of Dementia with Lewy Bodies. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e932018. [PMID: 34230446 PMCID: PMC8272938 DOI: 10.12659/ajcr.932018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Patient: Female, 92-year-old Final Diagnosis: Dementia with Lewy bodies Symptoms: Catatonia Medication:— Clinical Procedure: Biomarker Specialty: Neurology • Psychiatry
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Affiliation(s)
- Yusuke Saito
- Department of Psychiatry, Yamagata University School of Medicine, Iidanishi, Yamagata, Japan.,Department of Psychiatry, Okitama Public General Hospital, Nishiotsuka, Yamagata, Japan
| | - Keisuke Noto
- Department of Psychiatry, Yamagata University School of Medicine, Iidanishi, Yamagata, Japan
| | - Ryota Kobayashi
- Department of Psychiatry, Yamagata University School of Medicine, Iidanishi, Yamagata, Japan
| | - Akihito Suzuki
- Department of Psychiatry, Yamagata University School of Medicine, Iidanishi, Yamagata, Japan
| | - Daichi Morioka
- Department of Psychiatry, Yamagata University School of Medicine, Iidanishi, Yamagata, Japan
| | - Hiroshi Hayashi
- Department of Psychiatry, Yamagata University School of Medicine, Iidanishi, Yamagata, Japan
| | - Koichi Otani
- Department of Psychiatry, Yamagata University School of Medicine, Iidanishi, Yamagata, Japan
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Garcia Ruiz PJ. Electroconvulsive Therapy and Movement Disorders. New Perspectives on A Time-Tested Therapy. Mov Disord Clin Pract 2021; 8:521-524. [PMID: 33981784 DOI: 10.1002/mdc3.13180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 01/24/2021] [Accepted: 02/14/2021] [Indexed: 11/07/2022] Open
Abstract
Electroconvulsive therapy (ECT) has been a very well known therapy in Psychiatry for over 80 years. ECT is considered useful in treating acute mania, severe depression and other psychiatric conditions. Over time, this therapy has also been used in several movement disorders including Parkinson disease (PD) and Huntington disease (HD). In this brief review, I summarize the recent History and evolution of ECT, its proven and potential applications in movement disorders as well as its potential mechanisms.
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Affiliation(s)
- Pedro J Garcia Ruiz
- Movement Disorders Unit, Department of Neurology Fundacion Jimenez Diaz Madrid Spain
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Ramesh V, Sharma A, Sharma V, Somani A. Treatment of Catatonia in Parkinson's Disease with Electroconvulsive Therapy. Ann Indian Acad Neurol 2019; 22:501-503. [PMID: 31736583 PMCID: PMC6839294 DOI: 10.4103/aian.aian_308_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 07/15/2018] [Accepted: 07/16/2018] [Indexed: 01/07/2023] Open
Abstract
Parkinson's disease (PD) is known to have associated nonmotor manifestations including psychiatric symptoms such as depression and psychosis. Catatonia has been reported extremely rarely in patients of PD. The case described here is a rare example of catatonia in a patient with PD with psychosis. Treatment with electroconvulsive therapy (ECT) brought improvement in symptoms of both PD and catatonia. ECT appears to be an effective treatment option in patients of PD, especially with psychiatric manifestations.
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Affiliation(s)
- Vinutha Ramesh
- Department of Psychiatry, Adesh Medical College and Hospital, Kurukshetra, Haryana, India
| | - Ashish Sharma
- Department of Psychiatry, Adesh Medical College and Hospital, Kurukshetra, Haryana, India
| | - Veenita Sharma
- Department of Anaethesiology, Adesh Medical College and Hospital, Kurukshetra, Haryana, India
| | - Aditya Somani
- Department of Psychiatry, Adesh Medical College and Hospital, Kurukshetra, Haryana, India
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Lenka A, Gomathinayagam V, Bahroo L. Approach to the management of psychosis in Parkinson’s disease. ANNALS OF MOVEMENT DISORDERS 2019. [DOI: 10.4103/aomd.aomd_27_19] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Nishioka K, Tanaka R, Shimura H, Hirano K, Hatano T, Miyakawa K, Arai H, Hattori N, Urabe T. Quantitative evaluation of electroconvulsive therapy for Parkinson's disease with refractory psychiatric symptoms. J Neural Transm (Vienna) 2014; 121:1405-10. [PMID: 24744048 DOI: 10.1007/s00702-014-1212-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2013] [Accepted: 04/02/2014] [Indexed: 01/09/2023]
Abstract
Patients with advanced-stage Parkinson's disease (PD) occasionally experience refractory depression or catatonic stupor. Electroconvulsive therapy (ECT) has been reported as a successful procedure for both severe psychosis and motor symptoms in patients with PD. Four patients with PD who were receiving ECT were quantitatively evaluated using the Unified PD Rating scale part III, Hoehn and Yahr scale, Barthel index, Neuropsychiatric Inventory, mini-mental state examination, Revised Hasegawa's Dementia scale, Beck's Depression Inventory, and Hamilton Rating Scale for Depression-17. We adopted the "half-age" method, which is an age-based stimulus-dosing method. The patients showed improvement in symptoms of psychosis and motor symptoms without any adverse effects. The interval of improvement after ECT varied among patients. Of note, a decrease in psychiatric symptoms successfully alleviated the burden of caregivers. ECT may be useful to treat parkinsonism with refractory psychosis, major depression, or catatonic stupor, within the limitations of the patients enrolled.
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Affiliation(s)
- Kenya Nishioka
- Department of Neurology, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo, Tokyo, 113-8421, Japan,
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Adeosun SO, Hou X, Jiao Y, Zheng B, Henry S, Hill R, He Z, Pani A, Kyle P, Ou X, Mosley T, Farley JM, Stockmeier C, Paul I, Bigler S, Brinton RD, Smeyne R, Wang JM. Allopregnanolone reinstates tyrosine hydroxylase immunoreactive neurons and motor performance in an MPTP-lesioned mouse model of Parkinson's disease. PLoS One 2012; 7:e50040. [PMID: 23209637 PMCID: PMC3510204 DOI: 10.1371/journal.pone.0050040] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2012] [Accepted: 10/15/2012] [Indexed: 12/16/2022] Open
Abstract
Restorative/protective therapies to restore dopamine neurons in the substantia nigra pars compacta (SNpc) are greatly needed to effectively change the debilitating course of Parkinson's disease. In this study, we tested the therapeutic potential of a neurogenic neurosteroid, allopregnanolone, in the restoration of the components of the nigrostriatal pathway in MPTP-lesioned mice by measuring striatal dopamine levels, total and tyrosine hydroxylase immunoreactive neuron numbers and BrdU-positive cells in the SNpc. An acute treatment (once/week for two weeks) with allopregnanolone restored the number of tyrosine hydroxylase-positive and total cell numbers in the SNpc of MPTP-lesioned mice, even though this did not increase striatal dopamine. It was also noted that MPTP treated mice to which allopregnanolone was administered had an increase in BrdU-positive cells in the SNpc. The effects of allopregnanolone in MPTP-lesioned mice were more apparent in mice that underwent behavioral tests. Interestingly, mice treated with allopregnanolone after MPTP lesion were able to perform at levels similar to that of non-lesioned control mice in a rotarod test. These data demonstrate that allopregnanolone promotes the restoration of tyrosine hydroxylase immunoreactive neurons and total cells in the nigrostriatal tract, improves the motor performance in MPTP-treated mice, and may serve as a therapeutic strategy for Parkinson's disease.
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Affiliation(s)
- Samuel O. Adeosun
- Program in Neuroscience, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
| | - Xu Hou
- Program in Neuroscience, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
| | - Yun Jiao
- Department of Developmental Neurobiology, St. Jude Children's Hospital, Memphis, Tennessee, United States of America
| | - Baoying Zheng
- Department of Pathology, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
| | - Sherry Henry
- Department of Pathology, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
| | - Rosanne Hill
- Department of Psychiatry and Human Behavior, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
| | - Zhi He
- Department of Pathology, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
| | - Amar Pani
- Department of Developmental Neurobiology, St. Jude Children's Hospital, Memphis, Tennessee, United States of America
| | - Patrick Kyle
- Department of Pathology, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
| | - Xiaoming Ou
- Department of Psychiatry and Human Behavior, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
- Program in Neuroscience, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
| | - Thomas Mosley
- The Memory Impairment Neurodegenerative Dementia Research Center, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
| | - Jerry M. Farley
- Department of Pharmacology and Toxicology, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
- Program in Neuroscience, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
| | - Craig Stockmeier
- Department of Psychiatry and Human Behavior, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
- Program in Neuroscience, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
| | - Ian Paul
- Department of Psychiatry and Human Behavior, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
- Program in Neuroscience, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
| | - Steven Bigler
- Department of Pathology, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
| | - Roberta Diaz Brinton
- Department of Pharmacology and Pharmaceutical Sciences, University of Southern California, Los Angeles, California, United States of America
| | - Richard Smeyne
- Department of Developmental Neurobiology, St. Jude Children's Hospital, Memphis, Tennessee, United States of America
| | - Jun Ming Wang
- Department of Pathology, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
- Department of Psychiatry and Human Behavior, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
- Department of Pharmacology and Toxicology, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
- Program in Neuroscience, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
- The Memory Impairment Neurodegenerative Dementia Research Center, University of Mississippi Medical Center, Jackson, Mississippi, United States of America
- * E-mail:
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Abstract
Catatonia is a well-described neuropsychiatric syndrome that has been the subject of several texts. We present 4 cases seen on our academic service in the past 18 months and discuss significant features of each case.
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Usui C, Hatta K, Doi N, Kubo S, Kamigaichi R, Nakanishi A, Nakamura H, Hattori N, Arai H. Improvements in both psychosis and motor signs in Parkinson's disease, and changes in regional cerebral blood flow after electroconvulsive therapy. Prog Neuropsychopharmacol Biol Psychiatry 2011; 35:1704-8. [PMID: 21605615 DOI: 10.1016/j.pnpbp.2011.05.003] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2011] [Revised: 05/02/2011] [Accepted: 05/08/2011] [Indexed: 01/22/2023]
Abstract
PURPOSE Psychotic symptoms in Parkinson's disease (PD) are relatively common and, in addition to creating a disturbance in patients' daily lives, have consistently been shown to be associated with poor outcome. The use of anti-PD medications has been the most widely identified risk factor for PD psychosis (PDP). However, the pathophysiology of PDP remains unclear. Although the efficacy of electroconvulsive therapy (ECT) for PD had been pointed out, only one study has demonstrated the effectiveness of ECT on both psychotic symptoms and motor symptoms. The aim of this study was to examine the acute effectiveness of ECT on PD and to identify the brain areas associated with PDP. METHODS The study was conducted at Juntendo University Hospital in Tokyo. Eight patients with L-DOPA- or dopamine (DA) agonist-induced PDP, who were resistant to quetiapine treatment, were enrolled. Severity of PD was evaluated using the Hoehn and Yahr stage. Psychotic symptoms were evaluated using multiple measures from the Scale for the Assessment of Positive Symptoms (SAPS). Technetium-99m ethyl cysteinate dimer single photon emission computed tomography (99mTc ECD SPECT) was used to assess regional cerebral blood flow (rCBF) before and after a course of ECT. A voxel-by-voxel group analysis was performed using Statistical Parametric Mapping (SPM5). RESULTS Our study clearly demonstrated that PDP was significantly less severe after ECT than before ECT, as indicated by change in mean SAPS total domain score (t=7.2, P=0.0002). Furthermore, the patients showed significant improvement in Hoehn and Yahr stage after ECT (t=11.7, P<0.0001). A further notable observation was significant increase in rCBF in the right middle frontal gyrus after ECT. CONCLUSION We conclude that a course of ECT produced notable improvements not only in PDP but also in the severity of PD. The findings of change in rCBF suggest implications for dysfunction in the middle frontal region for patients with PDP.
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Affiliation(s)
- Chie Usui
- Department of Psychiatry, Juntendo University Nerima Hospital, 3-1-10 Takanodai, Nerima-ku, Tokyo 177-8521, Japan.
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