Treatment-Refractory OCD Responding to Maintenance Electroconvulsive Therapy

To The Editor: Electroconvulsive therapy (ECT) though a well established treatment for mood and psychotic disorders, does not find a mention as a treatment modality for obsessive compulsive disorder (OCD) in treatment guidelines.^{1, 2} The APA task force on ECT states that, unless severe depression is prominent, ECT is not an effective treatment option for patients suffering from OCD.³ However, there have been isolated reports and case series of ECT being used in OCD.^{2, 4, 5} We present a case of treatment-refractory OCD treated successfully with ECT alone.

Case Report

A 36-year-old single lady with 14-year history of treatment-refractory chronic OCD characterized by multiple obsessions (sexual, blasphemous, pathological doubts, magical thinking and need for exactness) and compulsions (ritualized washing, repeated reassurance seeking and proxy compulsions). She was refractory to adequate trials of fluoxetine, fluvoxamine, sertraline, and clomipramine and augmentation with clonazepam, buspirone, risperidone, aripiprazole, mirtazapine, topiramate and atenolol after being on treatment for 12 years. At the time of admission, she was already on fluoxetine 80mg and risperidone 2mg. Patient had severe avoidance evidenced by the fact that she would bathe once in 3 months, had not brushed her teeth in a year and avoided speaking, with indication of needs through gestures. Evaluation with Mini International Neuropsychiatric Inventory⁶ did not reveal depression or any other psychiatric diagnosis. Patient could not participate in cognitive behavior therapy inspite of repeated attempts in view of her severe anxiety. On admission, patient had a total score of 40 on the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS).⁷ Insight was fair on item 11 of the Y-BOCS, avoidance score was 4 (extensive and pervasive avoidance, circumscribed activities and maybe housebound) and CGI- severity score was 7 (most extremely ill).⁸

She was started on 3 times weekly bitemporal ECT. After first ECT, she began speaking. After 2nd ECT, Y-BOCS severity score had decreased to 12 each for obsessions and compulsions. After receiving 14 ECT, she was taking 15 minutes for bathing and she had a Y-BOCS severity score of 5 each for obsessions and compulsions, Avoidance score of 1 (mild, minimal and infrequent avoidance), CGI severity score of 3 (mildly ill), CGI improvement score of 2 (much improved) and MMSE score of 27/30. She was discharged after 5 weeks with a plan for weekly maintenance ECT since she had not shown any improvement with medications alone.

Patient did not come regularly for ECT. She had a relapse of symptoms within 2 months and had a Y-BOCS severity score of 20 each for obsessions and compulsions. She was restarted on 3 times weekly ECT. But developed significant memory deficits and hence ECT was stopped after the third one. Assessment of memory done using PGI memory scale revealed poor memory with total score of 0-20th percentile. She was then given 10 sessions of rTMS, with no improvement in symptoms and Y-BOCS score continued to be 20 each. She was started on 3 times weekly unilateral ECT but did not show any improvement, hence bitemporal ECT was started. She was then started on weekly bitemporal maintenance ECT. She continued fluoxetine 80mg, riperidone 2mg, memantine 10mg and atenolol 25mg.At 6 month follow-up, she showed partial response subjectively as well as through objective assessments and had become more functional in her daily life. At 6 month follow up, patient has a Y-BOCS score of 25 (reduction in YBOCS score by 37.5%; with Obsessions and Compulsions score of 12 and 13 respectively), CGI severity score of 4 (moderately ill), CGI improvement score of 2 (much improved) and MMSE score of 29/30.

Discussion

Reports of ECT in the treatment of refractory OCD is sparse in literature. In a cohort of nine patients in an open label study, transient improvements in OCD and depression.² In a review of 32 patients,⁴ it was reported that there was considerable improvement in refractory OCD and associated depressive symptoms .There is report of maintenance ECT for OCD refractory mainly to tricyclics.⁵ A majority of the patients in these reports, had comorbid depression contributions of variable treatments like cognitive behavioral therapy after ECT. The definition of treatment resistance in these studies was taken as resistance to tricyclics or a few SRIs, and none of the newer SRIs, augmentation strategies or modalities like rTMS were used. Hence, it is difficult to establish an independent anti-obsessional effect for ECT based on these reports.

This report demonstrates a case of OCD without any comorbidity, resistant to four SRIs, majority of augmentation strategies and transcranial magnetic stimulation, responding only to ECT. The initial response to ECT had been dramatic. After relapse, response was partial, but the patient was better functioning with maintenance ECT. This report illustrates that there is a need to reevaluate the role of ECT in treating severe OCD.