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Friday, February 8, 2008

3 Guidelines for ECT with Adolescents

ECT adolescents
So far I have found three guidelines about ECT with adolescents for depression. Summarized these guidelines suggest the following recommendations:

  • ECT is not recommended for children (5–11 years).

  • ECT should only be considered for young people with very severe depression and either life-threatening symptoms (such as suicidalbehaviour) or intractable and severe symptoms that have not responded to other treatments.

  • ECT should be used extremely rarely in young people and only after careful assessment by a practitioner experienced in its use and only in a specialist environment

This is roughly the conclusion after reading these three guidelines. This conservative opinion is based on the lack of controlled studies. Most publications on adolescents are reviews of single case studies or case series using variable methodology and variable outcome measures. This makes a positive publication possible, only positive outcomes are published.

Side effects are also not studied in controlled trials but only small retrospective case series and case reports. It seems that adolescents appear to have the same side effects as adults. There are no studies which provide evidence of the impact of ECT in developing brain.

Parents are generally as positive, or more positive in their views on ECT than adolescents who had received the treatment.

The above mentioned recommendations mainly come from the guideline of the National Institute of Clinical Excellence (NICE): Depression in children and young people
Depression in children and young people: identification and management in primary, community and secondary care.
Compared to the Practice parameters for the assessment and treatment of children and adolescents with depressive disorders of the American Academy of Child and Adolescent Psychiatry (AACAP)the NICE guideline is more comprehensive. In the AACAP guideline ECT is only mentioned for psychotic depression.
In adults, electroconvulsive therapy (ECT) is particularly effective for this subtype of depression. Non-controlled reports suggest that this treatment also may be useful for depressed psychotic adolescents.

The AACAP also has a guideline for ECT with Adolescents: Practice parameter for use of electroconvulsive therapy with adolescents.
This guideline has a far broader range of indications for ECT with adolescents.
  • Diagnosis: Severe, persistent major depression or mania with or without psychotic features; schizoaffective disorder; or, less often, schizophrenia. ECT may also be used to treat catatonia and neuroleptic malignant syndrome.

  • Severity of Symptoms: The patient's symptoms must be severe, persistent, and significantly disabling. They may include life-threatening symptoms such as the refusal to eat or drink, severe suicidality, uncontrollable mania, or florid psychosis.

  • Lack of Treatment Response: Failure to respond to at least two adequate trials of appropriate psychopharmacological agents accompanied by other appropriate treatment modalities. Both duration and dosage determine the adequacy of medication trials. It may be necessary to conduct these trials in a hospital setting.

  • ECT may be considered earlier in cases in which
    • adequate medication trials are not possible because of the patient's inability to tolerate psychopharmacological treatment;
    • the adolescent is grossly incapacitated and thus cannot take medication;
    • or waiting for a response to a psychopharmacological treatment may endanger the life of the adolescent.

I can live with the above mentioned first three points. I would like to develop two or three Dutch ECT centers especially for treatment of adolescents with extensive research protocols.
Ghaziuddin, N., Kutcher, S.P., Knapp, P., Bernet, W., Arnold, V., Beitchman, J., Benson, R.S., Bukstein, O., Kinlan, J., McClellan, J., Rue, D., Shaw, J.A., Stock, S., Kroeger Ptakowski, K. (2004). Practice Parameter for Use of Electroconvulsive Therapy With Adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, 43(12), 1521-1539. DOI: 10.1097/01.chi.0000142280.87429.68
&NA;, . (2007). Practice Parameter for the Assessment and Treatment of Children and Adolescents With Depressive Disorders. Journal of the American Academy of Child & Adolescent Psychiatry, 46(11), 1503-1526. DOI: 10.1097/chi.0b013e318145ae1c

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