Classics in ECT: 1997 Review of ECT in Adolescents in Am J Psych
"Classics in ECT" brings you this review from Australian colleagues:
Objective: Pharmacological treatments for certain psychiatric disorders in young people are often ineffective and may cause major side effects; thus, it is important to investigate other treatments. This article reviews the literature on the efficacy and safety of ECT in this age group and examines the evidence for the suggestion that it may be used inappropriately.
Method: All studies published in English and other languages on the use of ECT in persons 18 years of age or younger were obtained. The reports were systematically reviewed and rated according to the quality of the information in several domains, yielding an overall quality score for each study. Individual cases from each report were then examined and grouped according to diagnosis and response to ECT.
Results: Sixty reports describing ECT in 396 patients were identified; most (63%) were single case reports. The overall quality was poor but improved in the more recent studies. There were no controlled trials. Rates of improvement across studies were 63% for depression, 80% for mania, 42% for schizophrenia, and 80% for catatonia. Serious complications were very rare, whereas minor, transient side effects appeared common.
Conclusions: ECT in the young seems similar in effectiveness and side effects to ECT in adults. However, this conclusion is qualified by the lack of systematic evidence. More research and education of professionals and the public are needed. It is suggested that ECT registers be set up, that surveys and controlled trials be conducted, and that seizure thresholds, the optimal anesthetic, effects of concurrent medications, and cognitive consequences of ECT in the young be investigated.
IMPLICATIONS FOR EDUCATION
AND CLINICAL PRACTICE
ECT should be used with caution in young people because of the relative lack of knowledge. However, it may also be overlooked as a treatment alternative (278). Although a detailed discussion is beyond the scope of this review, it is worth speculating about why sections of the psychiatric profession and the community oppose the use of ECT in the young. One reason may be an antipathy toward ECT generally. This, in turn, has many determinants (94). The fear of adverse effects of ECT on the developing brain and the assumption that children and adolescents cannot fully understand—and thus cannot properly consent to—the treatment are often mentioned. Lack of knowledge of, or familiarity with, the procedure, particularly in the case of child psychiatrists, may also contribute to a negative perception of ECT. This is not surprising because of the low rates of utilization and the paucity of reports and because ECT is often ignored in textbooks on child and adolescent psychiatry (e.g., reference 95). Preliminary results of a survey of the majority (83%) of Australian and New Zealand child and adolescent psychiatrists (unpublished work of Walter et al.) showed that 40% rated themselves as having no knowledge or negligible knowledge about ECT in the young, and only 31% had firsthand experience of it.
The American Psychiatric Association offers guidelines for the use of ECT in the young (81). Similar
guidelines have been published recently by the Royal College of Psychiatrists (96). Other psychiatric associations should follow this lead.
Half a century of ECT use in young people.
Am J Psychiatry. 1997 May;154(5):595-602. doi: 10.1176/ajp.154.5.595.PMID: 9137112
The abstract is copied below:
Objective: Pharmacological treatments for certain psychiatric disorders in young people are often ineffective and may cause major side effects; thus, it is important to investigate other treatments. This article reviews the literature on the efficacy and safety of ECT in this age group and examines the evidence for the suggestion that it may be used inappropriately.
Method: All studies published in English and other languages on the use of ECT in persons 18 years of age or younger were obtained. The reports were systematically reviewed and rated according to the quality of the information in several domains, yielding an overall quality score for each study. Individual cases from each report were then examined and grouped according to diagnosis and response to ECT.
Results: Sixty reports describing ECT in 396 patients were identified; most (63%) were single case reports. The overall quality was poor but improved in the more recent studies. There were no controlled trials. Rates of improvement across studies were 63% for depression, 80% for mania, 42% for schizophrenia, and 80% for catatonia. Serious complications were very rare, whereas minor, transient side effects appeared common.
Conclusions: ECT in the young seems similar in effectiveness and side effects to ECT in adults. However, this conclusion is qualified by the lack of systematic evidence. More research and education of professionals and the public are needed. It is suggested that ECT registers be set up, that surveys and controlled trials be conducted, and that seizure thresholds, the optimal anesthetic, effects of concurrent medications, and cognitive consequences of ECT in the young be investigated.
The pdf is here.
And from the text:
AND CLINICAL PRACTICE
ECT should be used with caution in young people because of the relative lack of knowledge. However, it may also be overlooked as a treatment alternative (278). Although a detailed discussion is beyond the scope of this review, it is worth speculating about why sections of the psychiatric profession and the community oppose the use of ECT in the young. One reason may be an antipathy toward ECT generally. This, in turn, has many determinants (94). The fear of adverse effects of ECT on the developing brain and the assumption that children and adolescents cannot fully understand—and thus cannot properly consent to—the treatment are often mentioned. Lack of knowledge of, or familiarity with, the procedure, particularly in the case of child psychiatrists, may also contribute to a negative perception of ECT. This is not surprising because of the low rates of utilization and the paucity of reports and because ECT is often ignored in textbooks on child and adolescent psychiatry (e.g., reference 95). Preliminary results of a survey of the majority (83%) of Australian and New Zealand child and adolescent psychiatrists (unpublished work of Walter et al.) showed that 40% rated themselves as having no knowledge or negligible knowledge about ECT in the young, and only 31% had firsthand experience of it.
The American Psychiatric Association offers guidelines for the use of ECT in the young (81). Similar
guidelines have been published recently by the Royal College of Psychiatrists (96). Other psychiatric associations should follow this lead.
Because of reports of increased length of seizure and post-ECT convulsions, clinicians are advised to stop all nonessential medications while administering ECT.
Concurrent medications are used often and may be responsible for many of the adverse events. There is a case for determining the seizure threshold, for EEG monitoring, and possibly for EEG examinations before and after a course of ECT. Psychometric assessment before and some time after ECT would also be valuable.
. . . . She was allowed to go home two days after the last treatment and for the past three months has been get-ting along nicely and doing all things previously done in a satisfactory fashion.” This account by Perkins and Tanaka (18) of the dramatic effect of seven ECTs is hardly unique but illustrates vividly why we need to learn more about this treatment. It is sobering that our knowledge has grown so little beyond that which Heuyer and his colleagues acquired half a century ago.
Concurrent medications are used often and may be responsible for many of the adverse events. There is a case for determining the seizure threshold, for EEG monitoring, and possibly for EEG examinations before and after a course of ECT. Psychometric assessment before and some time after ECT would also be valuable.
Finally, consent issues require particular attention (81, 96). The parents and the child should be involved whenever possible and should be given adequate information. The opportunity to discuss ECT with other young people who have received it may be helpful (56).
CONCLUSIONS
“On February 10, 1977, electroconvulsive treatment was administered for the first time to a 16-year-old female who had not eaten, spoken or walked unaided for the past four months . . . . The first treatment produced an unclinching of the fists . . . . The second treatment produced consumption of small amounts of fluid . . . .The fifth was productive of eating and talking normally. . . . She was allowed to go home two days after the last treatment and for the past three months has been get-ting along nicely and doing all things previously done in a satisfactory fashion.” This account by Perkins and Tanaka (18) of the dramatic effect of seven ECTs is hardly unique but illustrates vividly why we need to learn more about this treatment. It is sobering that our knowledge has grown so little beyond that which Heuyer and his colleagues acquired half a century ago.
The publication of this comprehensive literature review in the American Journal of Psychiatry was a watershed moment that put ECT for children and adolescents on the map. Earlier reports by Fink and others had paved the way. Ending the review with a dramatic, yet quite typical, anecdote of rapid recovery is a nice touch.
In the ensuing 20+ years some things have changed: ECT for children and adolescents is slightly better accepted and child psychiatrists are somewhat more knowledgeable about ECT; self-injurious behavior/catatonia in children, adolescents and young adults with autism is appreciated as an important new indication for ECT; the call for guidelines has been answered. But other things have not changed: ECT for children and adolescents remains very uncommon (still likely lass than 1-2% of all ECT), many jurisdictions have age restrictions on ECT use, and most child psychiatrists remain woefully ignorant and dismissive of ECT. The conclusion that ECT for children and adolescents is underutilized remains.
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