Safety and Effectiveness of Electroconvulsive Therapy in Anorexia Nervosa and Depression – A Case Report and Effectiveness of Electroconvulsive Therapy in Anorexia Nervosa and Depression – A Case

Background: Anorexia nervosa (AN) mainly affects adolescents and young adults. AN is highly associated with comorbid psychiatric disorders such as depress-sion, which makes treatment difficult. Pharmacolo-gical options are limited because selective serotonin re-uptake inhibitors (SSRIs) are less effective in underweight individuals. Electroconvulsive therapy (ECT) is an important treatment option in these patients. Is this caution justified? Case presentation: We describe a 21-year-old woman with restrictive AN and depression, with suicidality. Trials of psychotherapy for depression and various antidepressants were unsuccessful and her condition deteriorated. She was admitted to hospital several times because of the precarious state of her health due to the eating disorder and serious suicide attempts. ECT was started because of the severe suicidality and her restrictive eating pattern. There were no complications, and the eating disorder and depression improved relatively soon after the start of treatment. ECT provided a breakthrough in the treatment of an unresponsive, life-threatening situation, such that follow-up therapy could be started. The eating disorder regressed several months after ECT. Conclusions: Case reports have their limitations and there is no unequivocal evidence that ECT is effective for AN with comorbid depression. Yet the literature suggests that ECT should be considered in a life-threatening situation or when treatment possibilities are exhausted. AN and underweight are not contraindications for ECT, although medical screening before treatment is highly recommended. The long-term effectiveness of ECT has yet to be established. Desensitization and Reprocessing;


Introduction
Eating disorders are common among adolescents and young adults, and girls and young women aged [15][16][17][18][19][20][21][22][23][24][25] years account for 95% of all patients with eating disorders in industrialized countries [1]. Current treatments include psychotherapy, nutritional counselling programmes, and medication [2], with weight restoration and stabilization of the patient's physical condition as primary treatment goals [1,3]. Cognitive behavioural therapy is the psychotherapy of first choice and is often effective [4]. However, it takes time, active participation and (self) perception in order to be productive. Moreover, underweight and mood instability often limit the effects of treatment [5].
Eating disorders have a high risk of relapse, leading to chronicity [6]. Anorexia nervosa (AN) is potentially the most life-threatening psychiatric disorder, with a mortality rate of 5.1 per 1000 person-years [7].
Eating disorders are often accompanied by mood, personality, or other psychiatric disorders [1]. The prevalence of severe depression is four times higher in patients with eating disorders than in patients without eating disorders [8]. Moreover, the severity of depression increases the risk of suicide and diminishes the likelihood of recovery from the eating disorder [9].
Pharmacotherapy may be useful in the treatment of comorbid disorders in AN, such as depression [10].
However, treatment with selective serotonin re-uptake inhibitors (SSRIs) for depression is less effective in the presence of AN [11], because the uptake of serotonin is inadequate in underweight patients [12].
Dutch guidelines recommend electroconvulsive thera-

Case Report
The patient was a 21-year-old Dutch woman with a history of restricting type AN and depression, with Worsening AN and depression led to the admission of the patient, who had a BMI of 11.5 kg/m 2 , to the psychiatric unit of a general hospital, where she underwent forced feeding. She was later admitted to a clinic for eating disorders. During this period, she was also diagnosed with an autism spectrum disorder (ASD) according to the current guidelines. Shortly after she was discharged to home, on the condition that she maintained a minimum weight (BMI 14 kg/m 2 ), she overdosed on paracetamol and was re-admitted to hospital. Because her BMI was 12 kg/m 2 , a weight recovery programme was started, but the patient did not follow the programme and refused to participate.
She again attempted suicide with 150 tablets of paracetamol (500 mg), and was admitted to the intensive care unit with severe liver enzyme abnormallities (ALAT and ASAT 7000 U/l).
The patient had already approached the Expertise Centre Euthanasia, but her request was denied on the grounds that there were still treatment possibilities, such as ECT. In consultation with the patient and her parents, it was decided to start ECT because of the

Effect of ECT on AN and depression
In their systematic review, Pacilio  year-old patient with AN and depression [20].
However, the eating disorder and depression regressed immediately after the end of ECT, prompting the restart of ECT, followed by transient maintenance ECT. The patient's BMI increased from 14.35 to 18.59 kg/m 2 during ECT treatment, and she became motivated to follow outpatient treatment, which led to a further improvement.

Safety
Serious side effects of ECT were not reported in the published case reports and were not seen in our patient. AN is not a contraindication for ECT [13].

Long-term effect
The recommended to achieve optimal treatment and stabilization of physical abnormalities. In this case report, ECT provided a therapeutic breakthrough in a patient in a serious condition with suicidality and an extremely restrictive eating pattern, such that it was possible to start follow-up treatment.

Ethics approval and consent to participate
Not applicable.