Visual hallucinations following electroconvulsive therapy for major depressive disorder
- 1 Medicine, Western University, London, Ontario, Canada
- 2 Ophthalmology, Western University, London, Ontario, Canada
- 3 Psychiatry, Western University, London, Ontario, Canada
- 4 Geriatric Psychiatry and Medicine, Western University, London, Ontario, Canada
- Correspondence to Hayden P Nix; hnix@uwo.ca
Abstract
A female geriatric patient with major depressive disorder, current episode severe, received eight right unilateral electroconvulsive therapy (ECT) treatments over the course of 3 weeks. After her third treatment, she began experiencing brief visual hallucinations, each lasting less than 5 s, consisting of dark to grey coloured, poorly defined geometric shapes and objects. These episodes occurred only during the day with no change in consciousness. With each additional treatment, the episodes increased in frequency, reaching a crescendo of approximately 20 episodes per day. After terminating ECT, the frequency of these episodes decreased and then ceased 6 weeks later. Neuroimaging and ophthalmological investigations discounted a space occupying lesion or vision loss. This case demonstrates a close temporal relationship between ECT and new onset visual hallucinations. Clinicians should be aware of the possibility that elderly depressed patients may develop visual hallucinations during a course of ECT.
Background
Major depressive disorder is a leading cause of disease burden and is projected to become the most common cause of disease burden in high-income countries by 2030.1 In individuals over 65 years of age, it has an estimated prevalence of 5.5%.2 Undertreated depression is associated with increased morbidity and mortality.3 First-line treatments for major depressive disorder include antidepressant medications (eg, selective serotonin reuptake inhibitors) and psychotherapy (eg, cognitive behavioural therapy). While these interventions are commonly effective, they do not provide benefit to all patients. Some patients require alternative modalities to alleviate their symptoms.
Electroconvulsive therapy (ECT) is a procedure in which electrical stimulation is applied to the skull under anaesthesia and muscle relaxant to produce a modified generalised seizure. It is a highly efficacious treatment for major depressive disorder as per current evidence.4–6 However, ECT is known to cause a range of adverse effects. Well-established adverse effects include disorientation, impairments in learning, anterograde amnesia and retrograde amnesia.7 For many patients, the risk of these adverse effects, in combination with the stigma surrounding this treatment deter them from agreeing to undergo this treatment, despite its efficacy.7
In this article we report an adverse effect of ECT that, to our knowledge, has not been previously documented. A female geriatric patient with treatment resistant major depressive disorder experienced brief intermittent visual hallucinations following right unilateral ECT.
Case presentation
A female geriatric patient with a 15–20-year history of major depressive disorder, recurrent, was presented to a geriatric psychiatry clinic in London, Canada. In the past she had undergone trials of buspirone, citalopram, desvenlafaxine, doxepin, escitalopram, mirtazapine, paroxetine, sertraline, trazodone and venlafaxine. In addition, she had a history of trials of quetiapine and risperidone as mood augmenting agents. These medications were either ineffective or had caused intolerable adverse effects.
On presentation she described her mood as ‘low and anxious,’ subjectively rating it 0/10, where 10 is the best possible mood. She reported anhedonia, insomnia, low energy, guilt, hopelessness and an inability to sit still for long. Her assessment scores were as follows: Hamilton Depression Rating Scale-17: 15, indicating moderate depression; General Anxiety Disorder-7: 15, indicating moderately severe anxiety and Patient Health Questionnaire-9: 16, indicating moderately severe depression. Her and the Montreal Cognitive Assessment Score was 25/30, with deficits in the Visuospatial (3/5), Naming (2/3), Attention (5/6) and Delayed Recall (4/5) domains, indicating mild cognitive impairment. These findings confirmed a diagnosis of treatment resistant major depressive disorder, current episode severe, without psychosis (current or lifetime). She additionally met criteria of a separate diagnosis of generalised anxiety disorder.
She provided voluntary and informed consent to receive ECT and received a total of eight right unilateral ECT treatments over the span of 3 weeks. After her third treatment, she began experiencing brief visual hallucinations in the days following treatment sessions. She perceived dark to grey coloured, poorly defined geometric shapes, shadows of human faces and everyday objects (eg, blankets) in the centre and to the side of her visual fields. Each time, she perceived the stimulus for less than 5 s and had trouble identifying the image. She perceived the objects and shapes as being in physical space in front of her. These episodes occurred during the day, while the patient was awake and alert. The patient retained insight during these experiences and was always aware that the images were not real. The visual hallucinations were not accompanied by other typical adverse effects of ECT such as somatic (pain) symptoms, amnesia or disorientation. She reported that she was emotionally very distraught by the visual hallucinations stating that they caused her to feel like she was ‘in a haunted house.’ She denied ever having such experiences in the past.
The frequency of the episodes increased with each subsequent ECT treatment. The frequency peaked at approximately 20 times per day after her eighth treatment. At this point, these episodes were intolerable to her and ECT treatment was therefore terminated. After ceasing ECT, the hallucinations gradually decreased in frequency and intensity, ultimately stopping completely 6 weeks after the last ECT treatment.
Despite these adverse effects, the ECT treatments improved her depressive symptoms significantly. She self-reported her mood as ‘pretty good’ and rated it as 7/10. Her scoring on all symptom questionnaires improved: her Hamilton Depression Rating Scale-17 decreased to 9, indicating mild depression; General Anxiety Disorder-7 decreased to 4, indicating minimal anxiety and Patient Health Questionnaire-9 decreased to 5, indicating mild depression. Her total Montreal Cognitive Assessment Score remained unchanged at 25/30, with deficits in the Attention (5/6), Language (2/3) and Delayed Recall (2/5) domains, indicating mild cognitive impairment.
Her psychotropic medications remained unaltered during this time and included brexpiprazole 1 mg, nortriptyline 50 mg and zopiclone 15 mg once a day. She was asked to refrain from taking zopiclone on the nights before ECT treatments to prevent potential effects on ECT seizure duration. Mechanistically, the serum half-life of zopiclone is approximately 5 hours, meaning that approximately 25% of the peak blood concentration will remain after 10 hours and receptor occupancy in the brain may decrease at a slower rate. Further, some clinical evidence suggests that zopiclone may alter ECT seizure duration over 5 hours after administration.8
Investigations, differential diagnosis, treatment, outcome and follow-up
Several investigations were conducted to rule out alternative causes for the patient’s experience of visual hallucinations.
A head CT scan was negative for space occupying lesions, recent infarct, haemorrhage or any other structural abnormality.
The patient had a history of several ocular conditions including previous cataract surgery, superficial keratectomy in the right eye for anterior basement membrane dystrophy (irregular corneal epithelium), dry eye and a mild epiretinal wrinkle in the right eye. None of these conditions were reported to be sight-threatening and she maintained good visual acuities. Following the onset of visual hallucinations, a repeat ophthalmological assessment demonstrated visual acuities of 20/40 and 20/20, respectively, and failed to identify any conditions that may result in Charles Bonnet syndrome.
At the time of writing this report the patient has not received an ECT treatment in 9 weeks and has not had a visual hallucination in 4 weeks.
Discussion
To our knowledge, visual hallucinations are not a documented side effect of ECT. However, there have been reports of other psychotic symptoms associated with ECT. Antosik-Wójcińska and colleagues reported a case of ECT causing delusions of reference, persecution, agitation and olfactory hallucinations in a 46-year-old woman.9 These symptoms occurred after the fourth ECT treatment. ECT was subsequently stopped and the patient was treated with olanzapine for 11 days. Fourteen days after ECT was stopped, the psychotic symptoms resolved.
Janakiraman and colleagues reported a case of a 93-year-old patient who developed musical hallucinations after receiving ECT for major depressive disorder.10 These hallucinations began after her second ECT treatment. They were not distressing to the patient and were resolved few days after the final ECT treatment.
We report another form of psychotic adverse effect from ECT. Instead of delusional, olfactory or auditory hallucinations our patient experienced distressing visual hallucinations. The temporal relationship of her visual hallucinations with ECT indicates that ECT was likely the causative agent. The crescendo-decrescendo change in frequency in the visual hallucinations corresponded with the onset, accumulation and termination of ECT treatments. This temporal relationship, in combination with the lack of prior history of psychosis, indicates that these visual hallucinations were likely caused by ECT treatments. While Charles Bonnet syndrome was one of the main differentials of this patient’s presentation, the lack of vision loss and a significant ocular pathology, discounted this diagnosis.11 12
One limitation of our report was that we could not complete a timely electroencephalography (EEG) to rule out ECT induced ictal pathology and a subsequent postictal psychosis presenting as visual hallucinations. However, postictal psychosis is unlikely to account for her presentation because her mental status was otherwise unaltered and the visual hallucinations persisted for 6 weeks after the final ECT treatment without antiepileptic medications.
Patient’s perspective
I think that this manuscript lists all my experiences very well and I did not have anything more to add to enhance or contribute to it. This paper describes my adverse symptoms and their resolution after stopping ECT. Thank you for letting me play a role in this endeavour.
Learning points
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Electroconvulsive therapy (ECT) has been known to cause amnesia, headaches, body aches, disorientation and confusion. Psychotic experiences have been previously documented with ECT, though not well known. We should remain open to the idea that ECT can itself trigger psychotic processes.
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This is the first report, so far as we are aware, of visual hallucinations as a potential adverse effect of ECT when treating a geriatric patient with major depressive disorder.
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Thorough clinical assessments are important to rule out an ocular pathology such as macular degeneration, space occupying lesions in the brain, a full work up for delirium or a neurodegenerative process in any elderly patient presenting with visual hallucinations.
Ethics statements
Patient consent for publication
Footnotes
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Twitter @HaydenPNix
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Contributors HPN and AK led the development of the article and wrote the first draft. All the other authors (RM and RO) provided detailed comments and revisions on subsequent drafts of the paper. All authors approved the final version of the paper.
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Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
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Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
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Competing interests None declared.
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Provenance and peer review Not commissioned; externally peer reviewed.
- © BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.
References
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