Electroconvulsive therapy in an older patient with recurrent major depressive disorder and a permanent pacemaker: A...

Electroconvulsive therapy (ECT) is highly effective for severe or treatment-resistant major depressive disorder, including in older adults. In patients with permanent pacemakers, however, ECT may be avoided because of concern about device malfunction or arrhythmia.

We report a man in his 80s with recurrent major depressive disorder and a dual-chamber pacemaker for complete atrioventricular block. During the approximately 2 years before admission, the depressive episode achieved only partial remission despite mirtazapine 30 mg/day and trials of duloxetine 60 mg/day and venlafaxine 150 mg/day, then worsened acutely. Vortioxetine was introduced after admission, but severe symptoms persisted. Pre-ECT interrogation confirmed pacemaker dependence with only minimal intrinsic ventricular activity. After multidisciplinary preparation, approximately twice-weekly ECT was initiated using a Thymatron System IV device with initial bitemporal placement; stimulus dosing initially followed the half-age method, beginning at 40% (202 mC) with a brief-pulse stimulus. As seizure induction became difficult, augmentation included hyperventilation, theophylline premedication, switching to right unilateral placement, and ketamine anesthesia. Continuous monitoring and peri-ECT device checks showed stable function; no magnet application or reprogramming was required. The patient received 20 treatments. The 21-item GRID Hamilton Depression Rating Scale (GRID-HAM-D) score improved from 32 before ECT to 2 after the acute course. Mood, anxiety, appetite, and physical strength improved early, followed by more gradual improvement in psychomotor retardation. No clinically significant arrhythmias, pacemaker malfunction, oversensing, pacing inhibition, or serious hemodynamic complications occurred.

This case supports the feasibility of carefully planned ECT in selected older patients with permanent pacemakers, provided that multidisciplinary planning and practical device precautions are in place.