Safe Treatment of a Patient With an Ommaya Reservoir With Electroconvulsive Therapy
A 58-year-old Caucasian female with a history of diffuse large B-cell lymphoma presented with a severe depressive episode with psychotic features and intense suicidal ideation. She was diagnosed with diffuse large B-cell lymphoma 3 years before her first depressive episode. At the time of diagnosis, computed tomography of the chest, abdomen, and pelvis and bone marrow biopsy showed diffuse infiltration of bilateral kidneys, retroperitoneal soft tissue, pelvis, and spine. The patient started chemo-immunotherapy with hyper-CVAD (cyclophosphamide, vincristine, doxorubicin, and dexamethasone). After cerebrospinal fluid analysis revealed lymphoma cells, an Ommaya reservoir was placed for intrathecal chemotherapy.
Several months after starting chemotherapy, she experienced her first episode of depression characterized by decreased appetite, low energy, apathy, anhedonia, tearfulness, hopelessness, helplessness, worthlessness, delusions of guilt, and suicidal ideation. Trials of sertraline, fluoxetine, venlafaxine, and mirtazapine were ineffective or poorly tolerated owing to restless leg symptoms. Depressive symptoms improved with olanzapine augmentation; however, this was also discontinued owing to severe akathisia and acute dystonia. Electroconvulsive therapy (ECT) was discussed, and neurosurgical consultation was pursued before treatment to assess risks of treatment with the Ommaya reservoir, which were determined to be minimal.
The patient underwent an acute series of bifrontal ECT using a MECTA Spectrum 5000Q machine with the following settings: pulse width, 0.5 milliseconds; frequency, 40 Hz; duration, 2.25 seconds; current, 800 milliamps; energy, ranging 15 to 29 J. Methohexital was used as the anesthetic agent, and succinylcholine as the neuromuscular blockade. She received a total of 15 treatments on a tapering continuation schedule with full remission of symptoms and major improvements in functionality. The treatments were tolerated well without complication.