ECT in Kids: Safe, Effective, Robust and… Underutilized

Caroline Cassels

June 27, 2013

SAN FRANCISCO — Electroconvulsive therapy (ECT) for the treatment of severe mental illness in adolescents is safe, effective, and robust, new research suggests.

A 20-year retrospective study by investigators at the Mayo Clinic in Rochester, Minnesota, one of the few centers in the United States that uses ECT to treat children and adolescents, showed that among a treatment-resistant pediatric population, the procedure reduced symptoms of affective disorders, psychotic disorders, and other disorders up to 1 year post-treatment with a single series of ECT.

"Despite the controversy that certainly surrounds ECT use in adolescents, these results demonstrate it is a safe, reasonably well-tolerated, and effective treatment, especially for the most severely ill patients who have shown resistance to both pharmacotherapy and psychotherapy," principal investigator Chad Puffer, DO, at the Mayo Clinic, told Medscape Medical News.

"The findings also suggest that while ECT improves outcomes, it is not a cure. It is, however, able to improve functionality to the point where many of these patients can be treated as outpatients," Dr. Puffer added.

The study was presented here at the American Psychiatric Association's 2013 Annual Meeting.

Poor Public Image

ECT is one of the most effective treatments for major depression, said Dr. Puffer, a general psychiatry resident at the Mayo Clinic, with response rates in adults that are higher than those achieved with pharmacotherapy alone, and although somewhat limited, the literature does supports its use in children and adolescents.

In addition, the American Academy of Child and Adolescent Psychiatry also acknowledges ECT as an effective treatment in children and adolescents with severe illness in a practice parameter published on the Academy's Web site.

However, access to the procedure appears to be a challenge due to a lack of ECT facilities servicing children and adolescents, said Dr. Puffer.

He believes that a poor public image based on outdated misconceptions and the controversy over its use have led to subsequent underutilization of the procedure.

"People tend to shy away from its use, especially in children and adolescents, due to concern about potential side effects, such as memory loss," he said.

Much of this concern about the use of ECT stems from its use in the early post-war era of the 1940s and '50s, when it was conducted without the use of anesthesia or muscle relaxants, causing patients to experience violent convulsions and sometimes broken bones.

"The idea that this is a barbaric treatment is typically perpetuated by those who have not seen the treatments as they are currently administered," he said.

Today, patients are under full general anesthesia, and medications are administered to control muscle twitching.

"So although we are inducing a seizure, there are no tonic clonic movements that are typical of a full-blown seizure," said Dr. Puffer. In addition, he noted, the duration of the treatment is extremely short. Typically, it takes longer to prepare the patient for ECT than it does to administer the procedure.

Furthermore, he said, the general anesthesia used in ECT is very short-acting, and patients begin waking up as soon as administration of the anesthesia ceases. In addition, at the Mayo Clinic, ECT is done under the supervision of an anesthesiologist as well as a psychiatrist.

Severely Ill Population

For the study, the investigators examined the medical records of all patients from the ages of 12 to 19 years treated with ECT at the Mayo Clinic from 1993 to 2012. The study included 46 patients; 1-year follow-up data were available for 29 of the patients.

Using the Clinical Global Impression rating scales of symptoms (CGI-S) and improvement (CGI-I), the researchers compared outcomes immediately before and up to 12 months after ECT treatment

The majority of patients, said Dr. Puffer, were suffering from severe, recalcitrant, and frequently comorbid mood, anxiety, and psychotic illnesses — with about an even split between recurrent major depressive disorder and primary psychotic disorder. Other disorders included anorexia nervosa, catatonia, and schizoaffective disorder.

By and large, these were the most ill patients in the hospital. Most had attempted suicide at least once, and many had been hospitalized multiple times for a duration ranging from months to years, said Dr. Puffer.

"They were not in school, not functioning at any sort of high level, and were really, really struggling. Most were on at least 4 to 5 medications and, at a minimum, had experienced 3 medication failures prior to administration of ECT. Because the Mayo Clinic is a larger tertiary care center, many of these patients were referred to us from other psychiatric hospitals when they had failed to improve," said Dr. Puffer.

Of the 46 study patients 67% (n = 31), the majority were treated bitemporally, and 24% (n = 11) were treated unilaterally on the right side.

On average, patients received 10.4 treatments per treatment series; 76% (n = 35) only required a single treatment series. However, the investigators note that some patients required 2 (22%, n = 10) or even 3 series (2%, n = 1).

The researchers compared patients' status immediately prior to receiving their first treatment and immediately following the end of their first treatment series.

Reassuring Results

The investigators report that most adolescents who received ECT were able to reduce treatment intensity by 1 less medication 1 year after ECT than they were at treatment initiation. They also found that ECT reduced symptoms of affective disorders such as major depression and psychotic disorders, including schizophrenia.

"On average, patients went from being severely or extremely ill to moderately or markedly ill. So we are taking the sickest patients and we are getting them better — we're not getting them all the way better, but we were able get them to a point where they didn't necessarily have to be in the hospital year-round or weren't trying to actively kill themselves.

"They were able to get back to school, get back to their outpatient psychiatrists for continuing management, and get back into life — and most were able to achieve that in 1 course of 10 treatments," said Dr. Puffer.

The most common side effects were nausea (15.2%) and headaches (13%), followed by postemergent agitation (8.7%) and spontaneous seizure (4.3%).

One of the study's limitations was the lack of data on cognitive status before and after ECT, said Dr. Puffer. However, he noted, in general, the research suggests there is no global change in children's cognitive status following ECT.

"If anything, a lot of these kids [before treatment with ECT] were not attending school, and just the fact that we were able to get them back into school and back hanging out with their friends and developing appropriately represents an overall improvement in cognitive status."

"One of the questions I get asked a lot is whether we're concerned about causing memory impairment, and, of course, we don't want to cause any undue harm. But you really have to take a hard look at the risks and benefits [of ECT], recognizing these are the most severely ill children," he added.

In addition, ECT appeared to be durable, with the vast majority of study participants "doing well" up to 12 months with a single treatment series, a finding Dr. Puffer said is "encouraging."

Important Reminder

Commenting on the study for Medscape Medical News, Mark George, MD, professor of psychiatry, radiology, and neurosciences and director of the Medical University of South Carolina Center for Advanced Imaging Research as well as the Brain Stimulation Laboratory in Charleston, said that the study serves as a reminder to clinicians that ECT is a viable treatment option "available for extremely ill adolescents, and it works."

Dr. George added that more research is needed to improve the durability and reduce the side effect burden.

Also asked for comment, Charles Kellner, MD, director of the ECT service at Mount Sinai Hospital in New York City, said that the study verifies ECT's safety and efficacy in this patient population.

"I'm glad to see this study because it confirms what most experts in the field already know — that ECT is as safe and effective when used in adolescents as it is in older patients," Dr. Kellner, who is also professor of psychiatry and director of the Division of Geriatric Psychiatry at the Mount Sinai School of Medicine, told Medscape Medical News.

It also shows that when institutions like the Mayo Clinic use ECT in this age group, the outcomes are good and the treatment is safe and well-tolerated, he added.

Dr. Kellner agreed with Dr. Puffer that ECT is likely underutilized and believes better education is the answer.

"I think it is underutilized to a large extent, and part of the issue is that child and adolescent psychiatrists are often very poorly educated in the indications for ECT and the technique of ECT.

"The more educated people in the medical field and the lay public become about ECT, the more accepting they are of the treatment as a safe, effective, modern part of psychiatric medicine," said Dr. Kellner.

He noted that even with the emergence of many new neuromodulator therapies, such as transcranial magnetic stimulation for psychiatric illnesses, including treatment-resistant depression, ECT remains the gold standard for severe illness.

Dr. Puffer, Dr. George, and Dr. Kellner report no relevant financial relationships.

The American Psychiatric Association's 2013 Annual Meeting. Abstract NR7-34. Presented May 20, 2013.

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