Case report
A 23-year-old single, male, university student was admitted as an involuntary patient to the Department of Psychiatry, University Hospital Galway. He was brought to the hospital by the police, who had made an application for involuntary admission. He had presented with a 3-week history of increasingly erratic behaviour. He initially developed symptoms of overactivity, sleep disturbance (sleeping only 2–3 hours per night), increased sociability and inflated self-esteem. His behaviour became increasingly disorganised in the week before his hospital admission. He had become more hostile and physically threatening to others and had been arrested on two occasions for public order offences. He believed that he was on a special mission to end Ireland's financial crisis and to resolve a number of international crises, including political disturbances in the Middle East and North Africa. He believed that the Gardaí were trying to harm him and to obstruct him in the fulfilment of these missions.
He was disinhibited and aggressive on the day of his admission to hospital and had assaulted a family member. This action and his previous behaviour was described as being ‘completely out of character’ for him.
He had presented ∼6 months previously to the psychiatry services with non-specific anxiety and depressive symptoms. He was not prescribed psychotropic medication at that time and these symptoms fully resolved. He had no previous medical or psychiatric history of note. He had no history of substantial illicit drug use or an alcohol or drug-related disorder. He drank ∼10–16 U of alcohol per sitting on four occasions per month. He had smoked cannabis in the past on an infrequent basis. There had been an increase in his use of alcohol and cannabis in the week before his admission and subsequent to the onset of his disinhibited behaviour.
He had no prior history of disciplinary problems in school and had performed adequately in his university examinations up until his final year. There was no prior history of violence or involvement with the police. There was no known family history of mental illness. He was described premorbidly as a pleasant and somewhat reserved young man. He was diligent with his studies and well liked by friends and family.
On mental state examination on admission, he was dishevelled and unshaven in appearance. He was distractible, agitated, disinhibited and restless during the course of the interview. He stared excessively and was hostile, threatening and confrontational. He was dismissive and sardonic in manner. His speech was loquacious and pressured. There was evidence of tangentiality but no flight of ideas. His mood was elated. He displayed exaggerated self-importance with grandiose and persecutory delusions. There was no evidence of thought interference, passivity phenomenon or perceptual abnormalities. He had no evidence of cognitive dysfunction beyond inattention and distractibility. He had no insight into his mental illness.
Course of hospital admission
He was diagnosed with mania with psychotic symptoms. He had a full organic work-up over the course of his hospital admission. His physical examination, routine laboratory investigations and CT brain were normal. A urine toxicology screen was positive for cannabinoids but negative for benzodiazepines, opiates, amphetamines and cocaine. His condition continued to deteriorate in the days after admission despite high-dose haloperidol (up to 30 mg daily) and lorazepam (up to 16 mg daily) and he became increasingly hostile to staff and fellow patients. He did not respond to de-escalation or other non-physical interventions. On day 5 of his admission, he seriously assaulted a member of the nursing staff. His clinical condition required seclusion and he remained in continuous seclusion for a period of 26 days. He was unable to respond to limit setting and remained impulsive, confrontational, abusive and disinhibited, with frequent unpredictable aggressive outbursts. His disorganised behaviour included undressing, masturbating and voiding in front of staff and throwing faecal material at the window and door of his room. There were a further three assaults on nursing staff during the period of seclusion.
He received increasing doses of antipsychotic, mood-stabilizing and sedative medication. These included zuclopenthixol acetate (up to 700 mg over a 10-day period with no evidence of an improvement in his behaviour), olanzapine 10 mg t.d.s., clonazepam 2 mg q.d.s., sodium valproate 900 mg b.d., chlorpromazine 200 mg q.d.s., promethazine 50 mg b.d., lithium carbonate 400 mg b.d. (serum level 0.8 mmol/l at 5 days). The sodium valproate was discontinued at the time that lithium was commenced. He was sedated with medication, though he remained aggressive and his psychotic symptoms persisted unabated. He displayed extrapyramidal side effects including rigidity and bradykinesia, but experienced no other adverse effects such as falls, autonomic instability or pyrexia.
His episode of mania remained entirely refractory to treatment and his behaviour continued to be severely disturbed. On day 25 of his admission, a clinical decision was made to administer electroconvulsive therapy (ECT), given the lack of any response to pharmacotherapy. Given that he was unable to understand the nature and purpose of the proposed treatment or to weigh up the information relating to it, he received a second independent psychiatrist opinion in accordance with the Mental Health Act (MHA) (2001), Section 59(1) (b), which authorised a programme of ECT.
As his clinical condition precluded his safe transfer to the dedicated ECT suite, a general anaesthetic was administered to him in the seclusion room with a consultant anaesthetist, consultant psychiatrist and other medical and nursing staff present. The anaesthetic procedure was performed with appropriate resuscitation equipment on site and the patient was transferred under general anaesthetic to the ECT suite where he received the ECT treatment. He had a marked response after the first two ECT treatments and cooperated with administration of general anaesthesia thereafter until completion of the course of ECT. His aggressive and hostile behaviour and his psychotic symptoms abated. He was removed from seclusion after his second application of ECT and was placed on general nursing observation following the fifth ECT application. The degree of clinical response demonstrated allowed for a reduction and eventual discontinuation of chlorpromazine and clonazepam over the course of the 3-week ECT treatment. He received six applications of bilateral ECT treatment over 3 weeks, with a mean stimulus of 220 mC. On each application, he had a generalised seizure, with a mean duration of 30 seconds as recorded by an electroencephalogram. There was no evidence of any sustained cognitive dysfunction clinically after the course of ECT and he sustained a score of 30/30 on Folstein's mini-mental state examination (MMSE) (Folstein etal. Reference Folstein, Folstein and McHugh1975) between the last three treatments of the ECT programme and after its completion. However, it is worth noting that a limitation of the MMSE is its low reported levels of sensitivity and utility among individuals with mild cognitive impairment (Tombaugh & McIntyre, Reference Tombaugh and McIntyre1992). He remained mildly disinhibited in interaction, but had recovered sufficiently to be discharged from involuntary admission 3 weeks after the course of ECT was completed and to be discharged from hospital 1 week after this. On discharge from hospital, he was prescribed lithium carbonate 800 mg b.d. (serum level 0.7 mmol/l) and olanzapine 10 mg b.d.
He has been followed up regularly in outpatient clinics since the time of his discharge. His insight remains good and he is fully compliant with treatment. He acknowledges and accepts his diagnosis and the need to continue prophylactic medication. At 9 months of follow-up, he has had no recurrence of any mood disturbance, was well maintained on lithium alone and had returned to and successfully completed his degree course.
Informed written consent for the publication of this case study was obtained from the patient at the time of his recovery from the episode of mania.
Discussion
This case study demonstrated a rapid response and decline in the severity of symptoms of mania after the use of ECT. The more common use of ECT (including involuntary ECT) is in treatment refractory depression where its safe and effective use is supported by robust scientific evidence (Lisanby, Reference Lisanby2007). However, severe mania, which usually impairs insight and capacity to consent to treatment, remains an important clinical indication. A review of the published literature of five decades of the use of ECT in mania indicated that ECT is associated with remission or marked clinical improvement in 80% of manic patients and that it is an effective treatment for patients whose manic episodes have responded poorly to pharmacotherapy (Mukherjee etal. Reference Mukherjee, Sackeim and Schnur1994). However, the majority of evidence for its benefits in mania come from prospective non-randomized studies and from case series. The benefits of combining ECT with lithium for both acute and maintenance therapy were demonstrated in a prospective study that showed that the use of ECT followed by lithium therapy was associated with a greater clinical improvement than that seen with lithium treatment alone (Small etal. Reference Small, Klapper, Kellams, Miller, Milstein and Sharpley1988). The presence of agitation and the high clinical severity, which were evident in this case, are predictive of a good response to ECT (Small etal. Reference Small, Small, Milstein, Kellams and Klapper1985).
In addition to the distress caused to this patient, his family and staff by the prolonged episode of severe psychotic mania, it resulted in a consecutive period in seclusion of 26 days during which this patient was exposed to multiple high-dose medications in an effort to treat his mania and associated behavioural disturbance. Use of high-dose antipsychotic medication carries an increased risk of not only extrapyramidal side effects and cardiovascular morbidity (specifically QTc prolongation and arrhythmias) (Haddad & Anderson, Reference Haddad and Anderson2002), but also of neuroleptic malignant syndrome (Keck etal. Reference Keck, Harrison and Pope1989).
The Mental Health Commission have produced codes of practice governing the use of ECT in Ireland (Mental Health Commission, 2009, 2010), which indicate that it is used for ‘specific types of major mental illness’. The College of Psychiatry of Ireland has released a position paper on the use of ECT, which highlights the benefit of ECT in severe mental illnesses that are refractory to medication, including treatment-resistant mania (College of Psychiatry of Ireland, 2011). The guidelines produced by National Institute of Clinical Excellence (NICE) recommend that ECT be used for the rapid and short-term improvement of severe symptoms after an adequate trial of medication has been ineffective or if an individual's condition is considered to be potentially life threatening. The use of ECT is recommended by NICE for severe mania (National Institute for Clinical Excellence, 2003). In the recently published report on the Administration of Electroconvulsive Therapy in Approved Centres in 2009, 15 (out of 373) programmes of ECT administered in Ireland in 2009 were for mania (Mental Health Commission, 2011). It is common clinical practice in this country to retain ECT for treatment refractory cases of mood disturbance. The markedly swift response once ECT was initiated in this case demonstrates how effective it can be for severe mania and clinicians might consider utilisation of ECT at an early stage in the treatment of such severe affective illness.
This case also underlines the need to retain the legislative capacity for treating patients with ECT when they lack capacity to consent to such treatment, a pertinent issue in the context of the recent Private Member's Bill in the Seanad [Seanad Eireann, Mental Health (Involuntary Procedures) (Amendment) Bill, 2008], which proposes to prohibit the prescription of ECT for involuntary patients who do not consent (Dunne etal. Reference Dunne, Kavanagh and McLoughlin2009). Section 59(1) of the Irish MHA states that a detained person can be given ECT with their written consent or, when ‘unable or unwilling’ to give consent, can be given ECT if their consultant psychiatrist along with another second opinion psychiatrist jointly approves a programme of ECT (Oireachtas na hEireann, MHA, 2001). In March 2010, the College of Psychiatry of Ireland in a submission to an All Party Seanad briefing recommended amending the MHA 2001 to delete ‘or unwilling’ from Section 59(1) (b) [Statement on ECT & Section 59(1) (b) of MHA, 2010]. Consistent with this view, a recent survey by our group found that the vast majority of consultant psychiatrists would approve the use of ECT when clinically indicated for involuntary patients who are unable to consent to such treatment, whereas the majority would not approve it for patients who are unwilling to consent (Schirliu etal. Reference Schirliu, Truszkowska and McDonald2011). It has been argued by some that the use of involuntary ECT should be prohibited in all cases and that Section 59(1) (b) should be deleted from the MHA (Bracken, Reference Bracken2011). This case study demonstrates how such legislative amendment could tip the balance away from the patient's best interest and prevent the provision of a treatment that was rapid, safe and singularly effective in the case of this patient. The forthcoming Mental Capacity Bill will provide a more general framework for treatment of patients who lack capacity, and it is possible that this act in future might enable the administration of ECT to incapacitated patients.
Conclusion
This case report highlights that ECT is a safe and effective treatment for severe psychotic mania. It can lead to a rapid improvement in a patient's clinical condition when pharmacotherapy has failed, and clinicians may consider its earlier use when swift resolution of manic symptoms is required. This case is illustrative of the benefit of such judicious use of ECT, and can serve to stimulate further debate and research regarding the use of ECT in mania.
Severe mania usually impairs judgement and such patients are often admitted involuntarily. There is a clear need to maintain in legislation the option of treating with ECT involuntarily admitted patients who are unable to consent to this treatment, in order that clinicians can act in the best interests of patients when they have the greatest need for effective treatment but the least capacity to choose it.
