Electroconvulsive Therapy in Solid Organ Transplant Recipients: A Case Illustration and Systematic Review of 18 Cases

Psychotic disorders in solid organ transplant recipients present complex diagnostic and therapeutic challenges. Tacrolimus, a commonly used immunosuppressant, is associated with neuropsychiatric side effects, yet discontinuation carries the risk of graft rejection. We describe a 65-year-old heart transplant recipient who developed very late-onset schizophrenia-like psychosis 54 weeks after transplantation while on tacrolimus. His psychotic symptoms-including hallucinations and delusions-were refractory to multiple antipsychotics, including clozapine, but responded substantially to bifrontal electroconvulsive therapy (ECT), with preservation of cardiac graft function. A relapse later improved with a second course of ECT. To contextualize this case, we reviewed 18 published reports of ECT in solid organ transplant recipients. Across depression, psychosis, catatonia, and suicidality, ECT consistently demonstrated effectiveness with mostly mild and manageable side effects, while rare severe complications were attributable to underlying medical conditions rather than ECT itself. These findings suggest that ECT is an effective consideration for refractory psychiatric syndromes in transplant recipients, even when immunosuppressant regimens cannot be altered. Careful pre-ECT evaluation, interdisciplinary collaboration, and vigilant peri-procedural monitoring remain essential for optimizing outcomes in this medically fragile population.