December 18, 1998

ECT can be used safely and effectively to treat adolescents with severe psychiatric disorders. It should be considered when medications are contraindicated or when previous treatments have failed.

So said Garry Walter, M.D., a child, adolescent, and family psychiatrist in Concord West, Australia, who spoke at the American Academy of Child and Adolescent Psychiatry (AACAP) meeting in October in Anaheim, Calif.

ECT is seldom used in this population because of concerns about side effects, especially prolonged seizures that could potentially damage the developing brain. It is also avoided because of a lack of knowledge, said Walter.

His review of the research literature, however, showed treatment results including side effects similar to those reported for adults.

Overall, of 396 cases reported through 1996, psychiatric symptoms improved early in the course of ECT treatment. (The mean number of treatments was 10). "This early improvement is particularly gratifying because, typically, these adolescents have been ill for many months and haven't responded well to other treatment approaches," said Walter.

Rates of improvement across published studies were 80 percent for catatonia, 80 percent for mania, 63 percent for depression, and 42 percent for schizophrenia.

Walter noted that ECT was used as a last resort in 92 percent of the reported cases. Prior unsuccessful treatments included antidepressants, antipsychotics, and a combination of the two classes of drugs.

There were no reported fatalities or long-term adverse problems associated with ECT. The most common complaints were headaches, subjective memory loss, manic symptoms, and disinhibition.

"The literature supports that ECT can be used safely in adolescents with no serious side effects," commented Walter.

Because the literature lacked systematic studies of ECT in adolescents, however, Walter conducted an epidemiological study of 42 adolescents who completed ECT treatment in hospitals in New South Wales in Australia between 1990 and 1996. The median age was 16 years.

His retrospective research appeared in the June 1997 Journal of the American Academy of Child and Adolescent Psychiatry.

ECT was administered on average three times a week per patient for 10 sessions. Improvement began on average after three ECT treatments.

Patients who experienced the greatest improvement had primary diagnoses of bipolar disorder and depression with psychotic features, which is similar to data on adults, said Walter. Depressive symptoms in schizophrenia also responded positively to ECT, which was consistent at the 23-month follow-up.

In contrast, schizophrenia-spectrum disorders with psychotic features responded poorly to ECT as did comorbid personality disorder.

Patients' primary psychiatric diagnoses were major depression, psychotic depression, mania, schizophrenia complicated by major depression, catatonic schizophrenia, and schizoaffective disorder.

Side effects included headaches, subjective memory problems, confusion, and nausea or vomiting. Prolonged seizures were reported in only two of the 49 cases. Walter commented that using the anesthetic propofol instead of thiopentone or methohexitone might reduce seizure duration. The mean duration of EEG-monitored seizures was 56 seconds.

EEG monitoring is one of the technological advances that has made the procedure safer to use with adolescents, Walter noted. It allows the clinician to measure seizure duration and cerebral seizure quality accurately.

Clinicians can also use "stimulant dosing" to calculate the dose of electricity needed to induce seizures based on individual factors such as age, gender, and electrode placement (unilateral or bilateral).

Walter said more research on ECT is needed in adolescents to further determine which diagnoses respond best to treatment and whether it causes structural changes in the developing brain.