Epilepsy is now defined as a disorder of the brain characterized not only by recurrent seizures but also by its neurobiological, cognitive, and psychosocial consequences. Psychiatric disorders are associated with a high risk of side effects of antiseizure medication whereas psychiatric comorbidities have been associated with 4 times the risk of drug resistance in focal and generalized epilepsies [18]. This is the second case series published on neuropsychiatric symptoms in epilepsy treated with ECT, the Lunde & Lee series was 43 patients, this is 33 patients corresponding to the patients reviewed from 2011 to date, there are several case reports with literature review that guide the use of this neuro modulation technique with safety and efficacy. For the present study we used the psychiatric symptom severity scale (CGI) at admission to the Neuropsychiatry Unit of the National Institute of Neurology and Neurosurgery (based on symptoms to examine the patient's changes he/she had throughout ECT) (Figure 3). The social limitations, the unpredictable nature of seizures, and the potential social embarrassment associated with them can lead to poor self-esteem, social withdrawal, isolation, and distress. At the same time, several biological factors contribute to the increased occurrence of psychiatric disorders. Psychiatric symptoms were more frequent in female sex, as well as single marital status, that speaks of functional systemic dysfunction of social relationships. Mood disorders and psychosis were the most comorbid clinical conditions and were the main reasons for admission to hospitalization, as well as the main reason for giving ECT, thirdly and very important to develop neuropsychiatric symptoms in epilepsy were with a difference of 15 years being the age of onset of epilepsy with an average of 15.4 years and the age that was given ECT with a mean of 33.7 years. Finally, in this case series all patients showed improvement in neuropsychiatric symptoms due to epilepsy after one course of ECT. Evidence suggests that the neuropsychiatric manifestations of epilepsy are multifactorial, including also the use of AEDs, there are neurochemical and structural changes associated with the seizure disorder as there appear to be common pathophysiological pathways in epilepsy and psychiatric disorders [11,12]. Several studies have shown increased volume in the hippocampus, amygdala, striatum suggesting neuroplasticity following ECT [13,14], as well as increases in several hormones (prolactin, thyrotropin, oxytocin, vasopressin and glucocorticoids) [15]. ECT causes neuroplastic changes: synaptogenesis, neurogenesis, dendrogenesis, angiogenesis and gliogenesis appearing as soon as after a single stimulus [16].  If the previously reported improvements of ECT with neuropsychiatric manifestations we consider it necessary to conduct further research on the subject, in this study the decrease in neuropsychiatric symptoms could be because caused by ECT in the central nervous system previously described. It should be taken into account that, being a retrospective case series, the diagnostic criteria used were from the DSM-IV and 5, however, we focused on the scales of severity of onset and termination of ECT respectively, due to the changes already described that patient undergoing ECT present, more studies are needed in patients with epilepsy and analyze the improvements that could have in addition to the neuropsychiatric symptoms and thus reduce the use of AEDs. Although initially controversy the available evidence supports that there are pathophysiological differences between seizures from epileptogenic regions in which the irritative area usually produces an increase in neuronal death for example when we use biomarkers such as S100B and neuronal specific enolase, and on the other hand, seizures provoked with ECT there is no supported evidence that it produces neuronal death being the available evidence in the opposite direction [17], Polyakova M, Schroeter ML, Elzinga BM, et al [18], reported in a meta-analysis and systematic review that ECT increases BDNF, in animal and human models, the presence of new neurons in the hippocampal area has also been reported, although the immediate cognitive effect of ECT is a decrease in recent memory, there is evidence of long-term cognitive recovery in patients with depression, for example, as evidenced in a meta-analysis of Ong Y, Chan LG [19,20]. With these findings we consider it pertinent to initiate a prospective study of the use of ECT and epilepsy in neuropsychiatric comorbidities with the aim of observing and describing the frequency of seizures pre and post treatment with neuromodulation therapies. Also, a necessary objective to study is the possibility of reducing AEDs. We consider that ECT treatment could be recommended in patients with epilepsy and neuropsychiatric symptoms, since all patients benefited in the resolution of affective and psychotic symptoms and there was also an increase in the MMSE score, which means improvement in cognition and without presenting epilepsy complications.

ECT parameters: 94.6% of the sample completed 4 sessions of ECT, 66.8% completed at least 6 sessions. The average stimulus dose went from 131.7 mCoulombs (mC) in the first session to 232.7 mC in session 6, the Thymatron System IV equipment provides a stimulus from 0 to 100 Joules corresponding to 0 to 504 mC; the duration of the post-stimulus EEG recording from 28.7ms to 29.4ms and that of the EMG from 26.7ms to 23.5ms. The mean MMSE score went from 19.8 to 20.0, thiopental from 187.9mg to 197.7mg, and succinylcholine from 55.8mg to 57.5mg, all from the first to the sixth session (Table 2).