ECT, Intellectual Disability, Catatonia: Case Report From India

Out on PubMed, from India, in the Journal of Pediatric Neurosciences, is this case report:

Use of Electroconvulsive Therapy in an Adolescent with Mental Retardation and Catatonia. Mehra A, Padhy S.J Pediatr Neurosci. 2021 Jan-Mar;16(1):58-60. doi: 10.4103/jpn.JPN_112_18. Epub 2021 Jun 25.PMID: 34316310

CASE REPORT
Year : 2021  |  Volume : 16  |  Issue : 1  |  Page : 58-60

Use of electroconvulsive therapy in an adolescent with mental retardation and catatonia

Aseem Mehra, Susanta Padhy
Department of Psychiatry, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

Date of Submission	14-Jul-2018
Date of Decision	18-Nov-2019
Date of Acceptance	26-Oct-2020
Date of Web Publication	25-Jun-2021

Correspondence Address:
Dr. Aseem Mehra
Department of Psychiatry, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh.
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jpn.JPN_112_18

 

Abstract

Despite the availability of electroconvulsive therapy (ECT) and being one of the safest modalities of treatment, the use of ECT is still underused in patients with mental retardation with catatonia. However, the available limited literature suggests that ECT can be used safely with proper monitoring and assessment, especially in those presenting with catatonia in mental retardation. We treated a 17-year-old boy who presented to us with catatonia with mental retardation with a course of 12 ECT, with which the catatonia resolved completely. Review of the literature suggests that the occurrence of catatonia is rare in mental retardation. However, ECT can be used in a rare case with precautions.

Keywords: Catatonia, electroconvulsive therapy, mental retardation

How to cite this article: Mehra A, Padhy S. Use of electroconvulsive therapy in an adolescent with mental retardation and catatonia. J Pediatr Neurosci 2021;16:58-60

How to cite this URL: Mehra A, Padhy S. Use of electroconvulsive therapy in an adolescent with mental retardation and catatonia. J Pediatr Neurosci [serial online] 2021 [cited 2021 Jul 29];16:58-60. Available from: https://www.pediatricneurosciences.com/text.asp?2021/16/1/58/319313

Introduction

The incidence and prevalence of primary psychiatric illness in children and adolescents with mental retardation are much higher than the general population.^[1],[2] Use of electroconvulsive therapy (ECT) is very limited in patients with mental retardation, however it has been used very effectively in the general population.^{[3],[4],[5],[6],[7]} Since last one decade, the trends favor the ECT’s efficacy, but still, this method is rarely used.^[4],[8] However, studies have also failed to show the clear evidence of brain insult following treatment with ECT.^[3] There are few case reports or case series that report of mental retardation associated with catatonia without any association with mood or schizophrenia disorder.^{[8],[9],[10],[11]} The limited data suggests that catatonia with mental retardation may respond to benzodiazepines and or ECT.^[12]

However, limited literature is available on the use of ECT in adolescents with mental retardation with catatonia. Here in this case report, we present a case report of a patient of mental retardation with catatonia without any affective or psychotic illness, and we also review the literature in the use of ECT in an adolescent with mental retardation.

Case Report

A 17-year-old boy presented with an insidious onset of illness since birth. The patient was born at 9 months by emergency cesarean section in view of meconium-stained liquor and fetal distress. He cried after 5–10min at birth after tactile stimulation. His birth weight was 3kg; after 24h of birth, he had recurrent episodes of seizures. The provisional diagnosis was kept as hypoxic ischemic injury. He was on antiepileptic drugs with good compliance. He had a significant developmental delay in all domains according to his appropriate age. At the age of 2 years, he again started having episodes of seizures and was managed accordingly by a pediatric neurologist. The developmental milestone delay continued as such. The frequency of seizures decreased significantly but would occur after every 6–8 months with good compliance. The last episode of seizure occurred at the age of 11 years. At the age of 11 years, he started to go to a special school for mentally retarded children. He had significant improvement in his behavior such as helping his mother with household chores, interacting with other children, playing games, counting the things, and emotional reactivity to external stimuli. This pattern continued till the age of 14 years. At the age of 14½ years, antiepileptic drugs were stopped gradually over a period of 2–3 months and maintained well for the next 2 years. Reportedly, he was scolded by a school teacher for not following their commands. Following which, he stopped going to school, would appear fearful, and would keep on saying “I will not go to school.” If a family member asked about the school, he would become aggressive, say teachers are bad, and will harm him. After 4–5 days of the same, he became mute, staring at one place with a fixed gaze, and not responding to external stimuli. He would walk very slowly, would urinate in clothes, and would keep on sitting in spoilt clothes for hours together. Other than these symptoms, drooling of saliva, negativism, ambitendency, and posturing were also present. Injection lorazepam test dose carried out with 2mg had significant improvement. He was started on tablet lorazepam 6mg/day. Initially he showed response but later he did not show any response. In view of the same, he was admitted to the inpatient unit of the psychiatry ward of the hospital. On mental status examination, the patient was found to have staring, negativism, automatic obedience, posturing, rigidity, ambitendency, mutism, negativism, staring, and drooling of saliva. His Bush–Francis Catatonia Rating Scale (BFCRS) score was 26. On investigation, hemogram, liver function test, renal function test, serum electrolyte levels, thyroid function test, ultrasound abdomen, X-ray chest (posterior-anterior view), and electrocardiogram did not reveal any abnormality. Magnetic resonance imaging of brain was suggestive of a reduction in the volume of the white matter with periventricular leucomalacia due to an old hypoxic insult. From clinical history and mental status examination, a diagnosis of mild mental retardation with catatonia was kept (epilepsy in the past). The dose of lorazepam was increased to 7mg thrice in a day. After giving a dose, he had significant improvement; BFCRS score came down from 26 to 6. Tablet olanzapine (5mg) was also started considering the fearfulness and odd behavior as psychotic symptoms, which occurred before the appearance of catatonic symptoms. The effect would last only for a few hours. He continued on tablet lorazepam 24mg/day in divided dose but did not show much improvement. It should also be noted that, despite this high lorazepam dose, he never became sedated or had any symptoms of respiratory suppression. Following this, he was considered for ECT.

His parents were educated about the ECT procedure and the indications for the same in the patient. A written informed consent was obtained from his father as he was his guardian. An attempt was also made to take the patient’s assent before initiating ECTs, but that could not be carried out considering his condition. He was then started on bilateral modified ECT.

As his clinical condition improved, his assent was sought for subsequent ECTs. During this period, the patient did not have any subjective complaints or objective signs of memory impairment or post-ECT delirium or other complications. By his 12th ECT, his BFCRS score came down from 26 to 1, and following this, two more ECTs were given. After attainment of a plateau of clinical response, ECTs were stopped. On mental status examination, he had no active psychopathology at the end of the course of ECT. He was discharged after 1 week of observation. He was continued on tablet olanzapine 15mg/day after discharge. At home, he again started going to school, with adequate function as noted before the occurrence of the illness.

Discussion

Despite the increased prevalence of mental illness in patients with mental retardation, the use of ECT is approximately three times less in patients with mental retardation.^{[1],[2],[3],[4]} Since the last few decades, increasingly consistent trends support the efficacy of ECT in the patient with mental retardation dual diagnosis.^[4],[7] The reason of underuse can be many, such as difficulty in obtaining informed consent, legal aspects, lack of empirical data, and organic brain damage, and moreover, the international guidelines have not made any recommendation for ECT in mental retardation.^[7],[12],[6]

There are approximately 100 published cases in the literature, which were managed with the use of ECT in mental retardation. Most of them are either case series or case reports.^[4],[13] No systematic review, case-controlled, or randomized controlled studies are available.^[14],[15]

The result of this case report showed that ECT can be used effectively in a patient with intellectual disability with catatonia. There is a need to reform the guideline for the use of ECT in mental retardation. The clinicians should take the initiative to carry out more research such as a randomized controlled trial and follow-up studies. In view of the same, rather than banning the use of ECT in adolescents, it would be better to leave the decision to use and not to use ECT in adolescents in the hands of the clinicians.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Borthwick-Duffy SA. Epidemiology and prevalence of psychopathology in people with mental retardation. J Consult Clin Psychol 1994;62:17-27.
2.	Van Waarde JA, Stolker JJ, Van der Mast RC. ECT in mental retardation: a review. J ECT 2001;17:236-43.
3.	Cutajar P, Wilson D. The use of ECT in intellectual disability. J Intellect Disabil Res 1999;43:421-7.
4.	Thuppal M, Fink M. Electroconvulsive therapy and mental retardation. J ECT 1999;15:140-9.
5.	Aziz M, Maixner DF, DeQuardo J, Aldridge A, Tandon R. ECT and mental retardation: a review and case reports. J ECT 2001;17:149-52.
6.	National Institute for Health and Clinical Excellence. Guidance on the use of electroconvulsive therapy (Technology appraisal 59). NICE; 2010.
7.	Scott AIF. The ECT handbook. London: Gaskell (Royal College of Psychiatrists). 2nd ed.; 2005.
8.	Little JD, McFarlane J, Ducharme HM. ECT use delayed in the presence of comorbid mental retardation: a review of clinical and ethical issues. J ECT 2002;18:218-22.
9.	Takaoka K, Takata T. Catatonia in childhood and adolescence. Psychiatry Clin Neurosci 2003;57:129-37.
10.	Mazzone L, Postorino V, Valeri G, Vicari S. Catatonia in patients with autism: prevalence and management. CNS Drugs 2014;28:205-15.
11.	DeJong H, Bunton P, Hare DJ. A systematic review of interventions used to treat catatonic symptoms in people with autistic spectrum disorders. J Autism Dev Disord 2014;44:2127-36.
12.	Muir WJ. The use of ECT in people with learning disability. In: Scott AIF, editor. The ECT handbook. 2nd ed. pp. 57-67. London: Gaskell (Royal College of Psychiatrists); 2005.
13.	Friedlander RI, Solomons K. ECT: use in individuals with mental retardation. J ECT 2002;18:38-42.
14.	Collins J, Halder N, Chaudhary N. Use of ECT in patients with an intellectual disability: review. Psychiatrist 2012;36: 55-60.
15.	Grover S, Kate N, Gupta G. Use of electroconvulsive therapy in an adolescent patient with catatonia. Indian J Psychol Med 2014;36:195-7.   [PUBMED]  [Full text]

This case report (with brief literature review) is a worthwhile contribution to the evidence base on the use of ECT for psychiatric conditions in patients with intellectual disability. It is interesting to note that the patient's catatonia developed soon after the psychological trauma of a scolding at school. The use of a neuroleptic in catatonia could be questioned; otherwise, the care received seems appropriate and the typical excellent resolution of catatonic signs/symptoms with ECT was seen.

The report is in a pediatric neurology journal; it is good for pediatric neurologists to get exposure to ECT; for that, kudos to these authors.