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BONE FRACTURE IS a rare complication in modified electroconvulsive therapy (mECT). However, cases have been reported where wrist fractures have occurred during mECT.1,2 Here we report a similar case with major depression.

A Japanese 58-year-old female patient who had suffered from repeated major depressive episodes (MDE) for 7 years was transferred to our hospital for mECT. Despite successful treatment for the first two MDE with amoxapine, the third MDE did not fully respond to clomipramine, fluvoxamine or milnacipran and a combination of antipsychotics. There was no history of manic or hypomanic episodes. Her menopause was at the age of 50. Laboratory tests showed a marked increase in serum prolactin (275.6 ng/dL) probably by concurrent medication with risperidone 8 mg/day. Magnetic resonance imaging showed no organic brain diseases. The patient was diagnosed with recurrent, severe major depressive disorder with psychotic features. The 17-item Hamilton score was 35.

After all psychotropic drugs were discontinued, she received the bilateral ECT with Thymatron DG (Somatics, Inc.; Lake Bluff, IL, USA) and standard procedures using succinycholine 40 mg. A cuff on the right forearm was inflated prior to administration of succinycholine. The average internal pressure of the cuff was above 250 mmHg: enough to block the influx of it. There were no additional constraints on any part of the patient's body. The physician in charge and nursing staff confirmed no potentially harmful objects around the patient. The energy percent was incrementally elevated from 30% to 50%, resulting in the mean electroencephalographic and electromyographic endpoints of 44.7 s and 28.5 s, respectively.

Immediately after the fifth treatment following four successful treatments, however, she complained of a sharp pain in the right wrist. Orthopedic surgeons diagnosed a fracture of the distal end of radius (Smith fracture) and performed internal fixation. As her depression was still profound, we continued mECT with a cuff alternatively being applied to the opposite forearm. After completing 10 treatments, her depressive symptoms were significantly alleviated. She was diagnosed with severe osteoporosis by dual-energy X-ray absorptiometry (DXA) of the lumbar spine.3 Bone mineral density was 0.584 g/cm2. T-score and % peak reference were −3.9 and 58%, respectively, while Z-score and % age-matched were −1.8 and 70%, respectively. Serum levels of calcium, phosphorus, intact parathyroid hormone and 1, 25-dyhydroxyvitamin D3 were normal.

Thus, unrecognized osteoporosis may have attributed to the patient's fracture on the right radius.1,3 We should have continued mECT without the cuff method or with a cuff on the ankle to avoid further fracture of the left radius.1 Regarding this case, in addition to depression,4 concurrent hyperprolactinemia may have been another potential risk factor for fractures.5 Further research is needed for DXA as a pre-ECT examination.

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