Successful ECT in an adolescent with catatonia and psychosis due to COVID-19

This case report highlights the use of ECT in an adolescent patient with a COVID-19 infection, which is an area of limited data. The patient received a full course of bitemporal ECT, with a total of 15 treatments administered over four months. The patient responded robustly, with a complete return to her pre-infection baseline mental status, and response has remained durable for one-year post continuation phase ECT taper. Maintenance ECT considerations for catatonia should be determined on a case-by-case basis but was not needed for our patient, given the durability of the response to ECT.


Introduction
Electroconvulsive therapy (ECT) is considered the gold standard treatment for catatonia, with guidelines recommending initiation of ECT in cases of catatonia which are refractory to treatment by benzodiazepines. While catatonia was originally conceptualized as a subtype of schizophrenia, the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV presented other causes of catatonia as secondary to other medical conditions. This change was further expanded in the DSM-V, where catatonia is postulated to independently arise in the context of multiple different psychiatric and other medical etiologies. Regardless of etiology, studies and case reports have shown that catatonia responds similarly to ECT ( Espi Forcen et al., 2022 ).  has been shown to cause both psychosis and catatonia in individuals who otherwise have no past psychiatric history or family history of psychiatric illness ( Ł o ś et al., 2021 ;Scheiner et al., 2021 ). Recent case reports have shown that psychotic symptoms related to COVID-19 may respond to treatment with antipsychotic medications as psychotic spectrum illnesses ( Ł o ś et al., 2021 ); case series have shown that catatonic symptoms related to COVID-19 may respond to lorazepam as catatonia due to any other cause ( Scheiner et al., 2021 ). However, literature is limited on whether ECT is effective for treatment-resistant psychosis or catatonia that is COVID-19 related.
For relapse prevention, there is no current guideline regarding utility of ECT taper or ECT maintenance in cases of catatonia. The duration of any maintenance ECT is also unclear. However, maintenance ECT is effective for relapse prevention following an initial series of ECT where relapse rates for depression may be high ( Jelovac et al., 2013 ). There are also case reports and small case series showing anecdotal evidence for its use for ECT in catatonia ( Lloyd et al., 2020 ) and for psychosis ( Ba ğcaz and Ba ş ar, 2023 ).

Case
Our patient is a 15-year-old female with no prior psychiatric history, family psychiatric history or history of drug use presented with catatonia and psychosis following a COVID-19 infection. The patient was an honors student, played competitive volleyball and had no prodromal symptoms concerning for childhood-onset psychosis. The patient had received her first dose of the Pfizer COVID-19 vaccine but then developed headache, weakness, fatigue, fever, and insomnia. Three days after her vaccination, the patient tested positive for COVID-19. After one week of being COVID positive the patient began experiencing photosensitivity, anxiety, grandiosity, erotomanic delusions about celebrities, and auditory hallucinations that they reported as "connecting with spirits. " The psychiatric manifestations coincided with the development of dysphagia, dyspnea, chest pain, nausea, and unintentional weight loss. The patient presented to the emergency room for evaluation but was discharged with only supportive care for their viral infection after the workup revealed no other etiology.
The patient returned to the Emergency Department (ED) one month later after their psychiatric symptoms had worsened as evidenced by persistent pacing and grimacing, gathering their belongings into a pile, wrapping them in a rug, and throwing them into the trash. The patient was then treated for pharyngitis and discharged, yet their psychiatric symptoms remained unaddressed until one week later. the ED, the patient manifested ongoing hallucinations and delusions and was admitted to the psychiatric hospital. The patient received olanzapine 2.5 mg per day for the next six days. Although stable at discharge, auditory hallucinations were only in partial remission. The patient relapsed within 48 h of discharge from the psychiatric hospital.
The next day, the patient was again brought to the ED with markedly worsened symptoms including smearing feces on the wall, severe insomnia, withdrawal, mutism, negativism, posturing, echolalia, and repetitive tapping of door locks. They underwent a more thorough neurologic workup including an electroencephalogram and head magnetic resonance imaging, both of which were unremarkable. Labs for both serum NMDA receptor antibodies and serum rapid PCR encephalitis panel were unremarkable. Cerebrospinal fluid was negative for herpes-simplex virus but revealed an elevated white blood cell count with spared glucose and protein -suggesting viral encephalitis.
The patient was admitted with a presumptive diagnosis of viral encephalitis secondary to COVID-19 and received five days of intravenous (IV) steroids and IVIG, as well as three days of Anakinra 10 mg IV every six q6 h with no improvement in symptoms. A lorazepam challenge revealed dramatic response at 2 mg, supporting a diagnosis of catatonia. This included a return of appropriate communication, better eye contact, resumption of normal appetite and drinking, and improved psychological thinking. Although Neuroleptic Malignant Syndrome was in the differential diagnosis, they did not manifest symptoms consistent with it such as autonomic instability, hyperpyrexia, leukocytosis, or elevated serum creatinine phosphorous kinase. The patient was then discharged from medicine service and transferred to the psychiatric hospital on lorazepam 2 mg three times a day and olanzapine 10 mg once at bedtime. Although partially improved, symptoms of catatonia and psychosis continued, so electroconvulsive therapy was recommended. While there were no scales for catatonia severity done, we agreed with the provisional diagnoses as being accurate based on the patient's symptoms and response to the lorazepam challenge.

ECT
Given the patient's Covid serological results, the medicine team considered them non-infectious at the onset of ECT. Over the next three weeks, the patient received a series of thrice weekly bitemporal ECT for a total of #7 treatments using a Thymatron device. The half-age dose calculation had failed to induce a seizure, so the total charge was titrated to 176mC charge (35% device energy, 0.5 ms) which generated a 43-second seizure. The patient continued this dose for the duration of their series. The catatonia, grimacing, posturing, and echolalia resolved after ECT #2, paranoia and auditory hallucinations remitted, and grandiosity and erotomanic delusions diminished after ECT #3. The patient was then discharged home, and ECT continued as an outpatient. By ECT #5, all symptoms were in full remission except a belief that the patient could communicate with their boyfriend telepathically. Their MMSE score during the inpatient portion of ECT treatments was initially 26/30. Due to olanzapine side effects of weight gain and sedation, the patient discontinued olanzapine abruptly and had a return of auditory hallucinations and grandiosity so was readmitted. The patient was started on risperidone 1 mg in the morning + 2 mg at night. By ECT #7 all psychotic symptoms were in remission. The patient received eight maintenance ECT treatments over the next four months. The patient's MMSE scores were not consistently 30/30 when maintenance ECT began but had become consistently 30/30 by completion of maintenance ECT. During this period, the patient resumed school, and began practicing volleyball with their teammates again. The patient and their family reported no noticeable decline in the patient's cognitive or athletic abilities compared to their pre-COVID state. They discontinued risperidone and ECT four months post-ECT series. One-year post-ECT the patient's symptoms remained in full remission.

Discussion
Case reports of ECT treatment for catatonia related to COVID-19 infection demonstrate safety and efficacy in adult patients with a previous psychiatric history ( Nikayin et al., 2022 ). This case highlights the safety and efficacy of ECT treatment in an adolescent patient with no previous psychiatric history, and one in whom the catatonia is suspected to have been precipitated by COVID-19. There is the possibility that remission of symptoms was unrelated to ECT, and a natural course of the illness resolved on its own or by antipsychotic medications. However, we note the response and remission was tightly coupled with the ECT treatments. The remitted state was durable, continuing into one-year post-ECT discontinuation. Moreover, our patient returned to their pre-COVID baseline level of social, athletic, and scholastic functioning.
The case report corroborates findings of other studies demonstrating efficacy in treating adult patients with ECT for catatonia in the context of COVID-19 infection. This patient tolerated the procedure well, demonstrated no cognitive impairments during or after treatment, and demonstrated a robust and fast response to ECT treatment. Given the relative scarcity of data on catatonia co-occurring in COVID-19 infections, further data are required before recommending maintenance ECT for patients who meet catatonia criteria. Data are also required to comment on the risk of adverse events in individuals with previous severe symptoms of SARS-COV-2, given the overall increased risk of cardiovascular, cerebrovascular, and respiratory events in these individuals. However, this case suggests that ECT can be performed safely in adolescent patients with neuropsychiatric sequalae of COVID-19 once they are deemed noninfectious and cleared for surgical procedures.
There is limited information on the role of maintenance ECT in catatonia. Most evidence on the use of maintenance ECT in catatonia derives from anecdotal case reports and series ( Lloyd et al., 2020 ). As such, guidelines remain to be developed. In this patient, given their lack of psychiatric history and a likely COVID-19 induced etiology of their psychosis and catatonia, it was decided to monitor for recurrence and to hold maintenance ECT. Remission continued over the following year, and the durability of the patient's response suggests this decision was appropriate for them. The choice of maintenance ECT is made on a caseby-case basis based on individual risk factors ( Rabheru, 2012 ).