Objective: This case report aims to highlight the ECT as a promising option on refractory neuropsychiatric manifestations of PD.

Background: In GBA-related PD, non-motor symptoms are more common than in idiopathic PD. Neuropsychiatric manifestations, part of non-motor symptoms, can be refractory;  there is a limitation on dose escalation of drugs to control the symptoms due to adverse effects of the drugs or aggravation of Parkinsonism. Electroconvulsive therapy (ECT) is a non-pharmacological treatment option in PD, particularly for refractory psychotic features.

Method: We present a case of a GBA-related PD patient who showed refractory psychiatric symptoms and her response to ECT.

Results: A 55-year-old woman visited our clinic for bradykinesia and leg pain. Mild anxiety, depression, and lability were checked in neuropsychiatric assessment scales on initial visits. Dopamine agonist and levodopa were applied and the dose of them gradually increased as motor and non-motor symptoms were continuously aggravated.
When she was 57, she attempted suicide. One year after the attempt, she complained off-pain of legs and back. Neuropsychiatric symptoms repeatedly presented as dopaminergic agents increased to control the off-pain. Consequently, she was admitted to the closed ward for severe paranoid delusion, hallucinations, anxiety, and depression. Despite the adjustment of antipsychotics and dopaminergic drugs, her off-pain was not effectively managed and neuropsychiatric symptoms relapsed.
To manage refractory features, we conducted right unilateral ECT. Scores significantly improved in various neuropsychiatric assessment scales.
One month later, quetiapine was decreased to 100 mg, and olanzapine was tapered out. L-dopa with entacapone was reapplied 2 months after the first ECT because of gait disturbance and severe off-pain. Additional courses of ECT were conducted due to depressive mood. Depression was properly controlled minimally using antidepressants.

Conclusion: This case presents the therapeutic effect of ECT in intractable psychiatric symptoms which are compatible with previous reports. Despite a long history and a series of evidence, ECT remains a reluctant option because of relatively unclear mechanisms and fear of side effects. However, ECT should be considered in PD with intractable psychiatric symptoms, including GBA-related PD, in which non-motor and psychiatric symptoms are more common than idiopathic PD.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/electroconvulsive-therapy-for-refractory-psychiatric-symptoms-in-gba-related-parkinson-disease-patient/