486. A case of prolonged delirium after the application of electroconvulsive therapy in the treatment of recurrent depressive disorder

Abstract

Abstract Background Electroconvulsive therapy (ECT) is an effective but underutilized treatment for depression that does not respond to antidepressants. Mild to moderate cognitive impairment is a common side effect, but usually resolves within a few hours. Aims & Objectives The main goal is a description of a patient who developed delirium after the sixth application of ECT. Method Using ECT for treatment for reccurent depression. Results A 62-year-old Caucasian patient was hospitalized for symptoms of recurrent depressive disorder. The patient's illness began 16 years ago with symptoms of a depressive disorder, which were reflected in moodiness, listlessness, lack of motivation, problems with sleep and appetite. Then outpatient treatment with antidepressants was started. Several therapeutic protocols have changed in the clinical discourse. Anafranil, escitalopram, duloxetine, trazodone were used as antidepressants, and quetiapine as an antipsychotic. The patient had several hospital treatments. Due to a poor response to pharmacotherapy, persistent and prolonged symptoms of a depressive disorder, she has been included in electroconvulsive therapy treatment since January 2025 with a frequency of three times a week. Each ECT was applied according to the protocol using bilateral electrodes with leptosuccin and propofol for anesthesia induction. The patient used pharmacotherapy with 5 mg olanzapine, 150 mg bupropion and 0.5 mg alprazolam. With the application of the first four ECTs, she had a slight improvement, after the fifth treatment the patient showed confusion, psychotic alienation from reality accompanied by hallucinatory phenomena. Treatment is continued administration of quetiapine in a daily dose of 150 mg, along with the antidepressant bupropion 150 mg and the benzodiazepine lorazepam in a daily dose of 7.5 mg. The clinical picture of a confused-delirious state lasted for five days. The patient continued to be treated with ECT, her condition improved over time, and she was without cognitive impairment at subsequent follow-ups. He still comes regularly for check-ups, uses esketamine in a dose of 86 mg in addition to the mentioned psychopharmaceuticals. Her functioning is stable over time, her mood and volitional-motivational dynamism are significantly better. The patient comes for regular checkups and administration of esketamine therapy, without ECT. Discussion & Conclusions Prolonged delirium after ECT is a rare clinical condition. So far, six cases of prolonged delirium associated with ECT have been registered. These cases show a rare but consistent pattern in which patients develop prolonged delirium after the third or fourth ECT treatment. Our case is unique because no obvious cause of prolonged delirium after ECT was found. Acute cognitive impairment after ECT is a frequently reported adverse effect, especially in the elderly population. Confusion usually begins immediately after ECT and typically lasts an hour or two; it spontaneously recedes. An acute confusional state lasting less than one hour is a common complaint reported in almost 12% of patients after ECT. Treatment involves careful monitoring of symptoms without prescribing pharmacotherapy. In cases of severe delirium, agents such as nitro-midazolam and antipsychotics can be used.