Electroconvulsive therapy for the neurological and psychiatric manifestations of multiple system atrophy

To the Editor

A 64-year-old businesswoman was admitted with treatment-resistant depression and multiple system atrophy (MSA). Three years earlier she had been diagnosed with MSA (parkinsonian type) with symptoms including slow gait, postural instability with falls, and symmetrical rigidity and bradykinesia of the limbs. She had autonomic involvement with hyperhydrosis, constipation and urinary frequency. Dopamine transporter imaging of the brain had shown symmetrical reduction in dopamine transporter binding in the striatum.

She had become depressed as her physical health declined. She had difficulty running her business, slept poorly and lost weight. She became increasingly anxious and fixated on her somatic symptoms. She distrusted medications, which she alleged worsened her symptoms. She took levodopa and pramipexole intermittently in small doses. These medications were poorly tolerated and did not improve her motor function. Numerous antidepressant medications were unhelpful.

On admission she was severely depressed, spending most of her time in bed. Her mobility was poor with a slow unsteady gait and she required assistance with activities of daily living (ADLs). She had urgency urinary incontinence.

She began standard pulse width (SPW) right unilateral electroconvulsive therapy (ECT) three times per week. By the sixth treatment there was obvious improvement in her mental state and neurological function. She became more reactive, less fixated on her physical symptoms and more engaged with staff. She gained independence with ADLs, her mobility improved, and her urinary incontinence decreased. Having previously refused medication she now accepted daily levodopa.

After the eleventh ECT treatment she had some memory impairment. Treatment was withheld but after 4 days it was evident that she was deteriorating. ECT was resumed with good effect, and she had a total of 18 treatments. The marked improvement in both depression and MSA with ECT was the first time this patient had responded to any intervention.

MSA is a rare neurodegenerative disorder frequently complicated by depression (Tison et al., 2006). The most common treatment is selective serotonin reuptake inhibitors. ECT has been used for the treatment of depressive and motor symptoms in Parkinson’s disease (Hooten et al., 1998), but there are only a few reports of its use in MSA (Husain et al., 2013).

This case suggests that unilateral SPW ECT can produce clinically significant improvements in patients with depression associated with MSA of the parkinsonian type. The improvement in her physical symptoms may have been due to the ECT, or could have been related to improved medication compliance. Maintenance ECT may be required to avoid relapse.