BMC psychiatry · 2025
Stereotactic lesioning combined with long-term Risperidone maintenance for life-threatening refractory suicidal command hallucinations in major depressive episode with psychotic features: a case report.
СтатьяКлинический случайНазвание и аннотация: Перевод пока не подготовлен
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Chen Cheng, Li Ruiting, Bai Hanping, Peng Yunlong, Wang Huiling
Аннотация
BACKGROUND: Refractory suicidal command hallucinations in major depressive episode with psychotic features constitute an acute clinical emergency, often unresponsive to multiple antipsychotics and electroconvulsive therapy (ECT), leaving clinicians with limited life-saving options. Stereotactic lesioning, as a last-resort intervention, may have some utility in such case; however, its long-term efficacy and the extent to which it depends on postoperative pharmacotherapy are not yet fully understood.
CASE PRESENTATION: A 20-year-old female with major depressive episode with psychotic features experienced 10-12 daily suicidal command hallucinations (with 4 suicide attempts within 1 week), refractory to 3 antipsychotics (Aripiprazole, Olanzapine, Risperidone) and 12 sessions of ECT (Montgomery-Asberg Depression Rating Scale [MADRS]: 30, Hoffman auditory hallucination score [Hoffman]: 25). Stereotactic bilateral lesioning of the anterior limb of the internal capsule and cingulate gyrus (SALIC-CG) resulted in a marked alleviation of symptoms within 1 week (MADRS: 7, Hoffman: 0). Notably, symptoms recurred 1 month postoperatively following antipsychotic discontinuation (MADRS: 22, Hoffman: 20) but resolved rapidly upon reintroducing Risperidone, with sustained remission at 6 months (MADRS: 6, Hoffman: 0) under continuous pharmacotherapy.
CONCLUSIONS: This case offers preliminary evidence that stereotactic lesioning may act as a key intervention for alleviating symptoms in patients with psychotic major depressive episode-specifically those with intractable suicidal command hallucinations that do not respond to all conventional treatments. Critically, it underscores that postoperative long-term antipsychotic maintenance is not merely adjunctive but essential to preserve surgical benefits, establishing a "surgery + long-term pharmacotherapy" paradigm with direct implications for managing high-risk refractory cases.
CLINICAL TRIAL NUMBER: It is not a clinical trial, clinical trial number: not applicable.
CASE PRESENTATION: A 20-year-old female with major depressive episode with psychotic features experienced 10-12 daily suicidal command hallucinations (with 4 suicide attempts within 1 week), refractory to 3 antipsychotics (Aripiprazole, Olanzapine, Risperidone) and 12 sessions of ECT (Montgomery-Asberg Depression Rating Scale [MADRS]: 30, Hoffman auditory hallucination score [Hoffman]: 25). Stereotactic bilateral lesioning of the anterior limb of the internal capsule and cingulate gyrus (SALIC-CG) resulted in a marked alleviation of symptoms within 1 week (MADRS: 7, Hoffman: 0). Notably, symptoms recurred 1 month postoperatively following antipsychotic discontinuation (MADRS: 22, Hoffman: 20) but resolved rapidly upon reintroducing Risperidone, with sustained remission at 6 months (MADRS: 6, Hoffman: 0) under continuous pharmacotherapy.
CONCLUSIONS: This case offers preliminary evidence that stereotactic lesioning may act as a key intervention for alleviating symptoms in patients with psychotic major depressive episode-specifically those with intractable suicidal command hallucinations that do not respond to all conventional treatments. Critically, it underscores that postoperative long-term antipsychotic maintenance is not merely adjunctive but essential to preserve surgical benefits, establishing a "surgery + long-term pharmacotherapy" paradigm with direct implications for managing high-risk refractory cases.
CLINICAL TRIAL NUMBER: It is not a clinical trial, clinical trial number: not applicable.