title: Electroconvulsive therapy in patients with skull defects or metallic implants: a review of the literature and case report.
abstract: BACKGROUND
  Head injury is often associated with psychiatric morbidity. While it is well understood that the loss of critical areas of the brain may play a role in cognitive dysfunction and change in personality, head injury can also have profound effects on mood and cognition. The role of medications in the treatment of mood disorders associated with brain injury is well documented, and there is also evidence favoring the use of electroconvulsive therapy (ECT) in this context. However, data are limited on the use of ECT in patients with skull defects or metallic head implants.
  
  
  METHODS
  First, a review of the literature on use of ECT in patients with metallic head implants is provided. Electronic databases and online sites, including PubMed, Cochrane Library of Systematic Reviews, and UpToDate, were used to search for relevant articles and case reports on the use of ECT in patients with and without metallic implants in the head (1964 to 2009). The search terms electroconvulsive, electroconvulsive therapy, ECT, electroshock therapy, EST, head injury, brain injury, metallic plates, metallic implants, skull prosthesis, and depression were used interchangeably. The search produced 7 articles discussing exclusively the use of ECT in patients with a metallic skull plate. Second, the case of the successful and safe use of ECT in an individual with a previous history of brain trauma and metallic plate implantation is described.
  
  
  RESULTS
  Most cases of head injury are managed by neurologists and rehabilitation consultants; the more severe cases of depression and other mood disorders tend to be referred for specialist psychiatric care. With greater degrees of deficit following head injury, management becomes more complicated. Our patient showed positive results with ECT, including improvement in depressive features and resolution of suicidal ideas/plans.
  
  
  CONCLUSIONS
  ECT is an effective and safe alternative in patients with a history of brain trauma and metallic plate implantation who subsequently develop treatment-resistant depression and associated suicidal ideas or plans refractory to management with medications.
authors.affiliation: Departments of Psychiatry (Drs Amanullah and Delva) and Medicine (Mr McRae), Dalhousie University, Halifax, Nova Scotia; and Departments of Psychiatry (Dr Amanullah) and Psychology (Dr Campbell), Hillsborough Hospital, and Queen Elizabeth Hospital (Ms Cole), Charlottetown, Prince Edward Island, Canada.
authors.forename: Shabbir
authors.initials: S
authors.lastname: Amanullah
authors.forename: Nicholas
authors.initials: N
authors.lastname: Delva
authors.forename: Harold
authors.initials: H
authors.lastname: McRae
authors.forename: Laura A
authors.initials: LA
authors.lastname: Campbell
authors.forename: Julie
authors.initials: J
authors.lastname: Cole