ECT: An Effective Treatment in the Screaming Demented Patient

To the Editor:—As a tertiary inpatient geriatric psychiatry program, we are often exposed to a common treatment dilemma, the screaming demented patient. Very little has been published in this area. The studies reporting on agitation are mostly medical descriptions and pharmacologic trials, with verbal agitation being included under the broader symptom cluster of physical or behavioral agitation.1,2 Agitation is usually poorly defined, and in no studies was verbal agitation considered as a separate variable. As a whole, the medication trials achieved only limited degrees of success. Experience dictates that these successes are often more than offset by medication side-effects and drug toxicity, thus further complicating the patient's presentation and course.3 Partly owing to this lack of effective treatment, Fogel4 suggested the need for further investigation of ECT in the screaming demented patient. Verbal agitation (needless, unstimulated screaming, yelling, moaning) occurs in many psychiatric conditions common to the elderly—delirium, dementia and depression. It is unclear whether this is the result of a common final neurochemical pathway or of differing etiologies in the different conditions.5 We wish to report on a small series of three elderly, verbally agitated patients who showed a dramatic improvement in this symptom with bilateral ECT. In none of these patients was ECT the initial treatment modality employed; neuroleptics, antidepressants, anticonvulsants or benzodiazepines were tried unsuccsssfully first. One patient clearly met the criteria for major depression and had a past history of ECT-responsive mood disorder. In the other two patients, there was no clear history of major depression either past or current; both had a substantial degree of cognitive impairment. All three patients, exhibited rapid resolution of their screaming behaviour early in their course of ECT. These pilot results suggest some interesting directions. Assuming response to ECT, this might support the hypothesis that screaming in dementia may be a presentation of depression where the other symptoms may be difficult to elicit. On the other hand, the response may suggest a specific response to electrotherapy. Irrespective of the mechanism, ECT appears to provide the possibility of effective therapy in the demented patient who screams and could provide an alternative to the more traditional approach of endless trials of progressively more toxic psychotropic drugs, singly and in combination, with poor outcome and potentially devastating toxicity.