Case Study: Electroconvulsive Therapy in Adolescents

Case Study: Electroconvulsive Therapy in Adolescents FRANTZ N. MOISE, M.D.,

AND

GEORGIOS PETRIDES, M.D.

ABSTRACT Objective: Recognizing the limited experience with electroconvulsive therapy (ECT) in adolescent psychiatric patients, the authors evaluated the efficacy, indications, and benefit of the treatment in this population. Method: The records of patients in the ECT rosters at University Hospital at Stony Brook between 1983 and 1993 were reviewed. Thirteen adolescents between the ages of 16 and 18 years who received ECT were identified. ECT followed the institution's standard adult protocol. Results: Ten patients were evaluated as responders, and three as nonresponders. Patients with diagnoses of an affective illness, unspecified psychosis, and catatonia benefited the most. Some improvements were seen in the patients with schizophrenia. Eight patients (62%) were contacted by telephone for follow-up. Five remain asymptomatic 3 years after the treatment, and three relapsed within 12 months despite maintenance pharmacotherapy. Conclusion: Within the limitation of record review and partial follow-up, ECT was found to be an effective and useful procedure in the treatment of adolescents with severe psychiatric disorders. J. Am. Acad. Child Ado/esc. Psychiatry, 1996, 35(3):312-318. Key Words: electroconvulsive therapy, adolescents, affective disorders, psychosis.

adolescents "has been acceptable to a small group of psychiatrists on rare occasions" (p. 162). The Consensus Development Conference on ECT (1985), sponsored by the National Institute of Mental Health and the National Institutes of Health, ignored the use of ECT in children and adolescents (Consensus Conference, 1985). Yet, a second American Psychiatric Association Task Force, reflecting a change in attitude, outlined recommendations for the use of ECT in postpubertal adolescents (American Psychiatric Association Task Force on Electroconvulsive Therapy, 1990). They recommended that the referrals for ECT be based on factors similar to those used in adults and that concurrence with the recommendation should be provided by a psychiatrist with experience in treating adolescents. For prepubertal children, however, they reserved ECT for instances in which other viable treatments had not been effective. Age was not considered a contraindication, but the authors found the data too limited to warrant specific recommendations, and they suggested that consultation be provided by two psychiatrists who are not involved with the case and who are experienced in the treatment of children before ECT is given to children. The use of ECT in adolescents is limited largely by lack of experience, fears that seizures may "damage" a developing brain, and the strong psychological and family bias of child and adolescent psychiatrists. In

Since its introduction more than 60 years ago, electroconvulsive therapy (ECn has been widely used in the treatment of adults with many forms of mental illness. Its primary indications are in patients with depressive and manic mood disorders, especiallythose with excitement, suicidality, and catatonia. In US academic medical centers, its use ranges from 5% to 15% of adult admissions; at least 36,000 patients received ECT in 1986 (Thompson et al., 1994). For a variety of reasons, ECT is rarely used in adolescents, and the literature is limited to case reports. Bertagnoli and Borchardt (1990) published an excellent review of the use of ECT in children and adolescents, in which most of the 151 reported cases aged 5 to 19 years improved. The American Psychiatric Association Task Force on ECT (1978) remarked that ECT in children and Accepted September 7, 1995. Dr. Moise is a graduate of Child and Adolescent Psychiatry Fellowship program, SUNY Stony Brook, and a staff psychiatrist, Sagamore Children's Psychiatric Center, Dix Hills, NY; Dr. Petrides is ClinicalAssistant Professor ofPsychiatry, SUNY Stony Brook, and a staffpsychiatrist, Northport Veteram Administration Medical Center, NY. A poster version of this paper was presented during the 1995 meeting of the Association for Convulsive Therapy in Miami. We are gratefUL for the collaboration and encouragement of Drs. Gabrielle Carlson and Max Fink. Reprintrequests toDr. Petrides, DepartmentofPsychiatry, School ofMedicine T-1O-040, Stony Brook, NY 11794-8101. 0890-8567/96/3503-0312$03.00/0©1996 by the American Academy of Child and Adolescent Psychiatry.

312

J.

AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 35:3, MARCH 1996

ECT IN ADOLESCENTS

1993, the Texas legislature banned the administration of ECT to persons younger than 16 years of age. This most recent limitation followed the enactment of legislation in California in 1974 that prohibits ECT in children younger than the age of 12 years. Colorado (1977) and Tennessee (1976) have similar bans on ECT in minors younger than 16 and 14 years of age. In a recent issue of The Lancet, Baker (1995) pleads for a ban on the use of ECT in adolescents in Great Britain, arguing that adolescents cannot give informed consent, and for fear of brain damage. The case literature is ambiguous in its conclusions regarding effectiveness. In one series, dramatic improvement is described in 9 of 10 adolescent patients with a delusional psychotic disorder who received ECT. They remained asymptomatic during a 3- to 4-year follow-up (Campbell, 1952). In a follow-up of 32 patients from the original series of 98 patients by Lauretta Bender (1947), Clardy and Rumpf (1954) report that the effects of ECT were "temporary and resulted in no sustained improvement in the patterning of behavior" (p, 616). The successful treatment of an l l-year-old depressed boy was reported by Black et al. (1985). After 12 unilateral ECT treatments, there was remarkable improvement of his depressive symptoms. The authors conclude that ECT is a valid therapy for children who are refractory to pharmacotherapy if they have depression, mania, or an acute schizophreniform psychosis. Guttmacher and Cretella (1988) describe four patients aged 12 to 15 years who received ECT, and only one had a favorable outcome. The three patients who did not respond exhibited prolonged seizures lasting longer than 4 minutes, suggesting that their seizure thresholds were remarkably low or that the energies used to induce seizures were exceptionally high. At a recent meeting of a child and adolescent consortium, the experience with ECT in four centers (46 cases) in addition to our own were reported. The reported risks included postseizure headaches (50%), two instances of prolonged seizures, and cognitive and memory effects during the course of treatment which did not persist after recovery (Consortium on Affective Disorders, Rhode Island, personal communication, 1994). Most recently, Cizadlo and Wheaton (1995) reported the successful treatment of major depression with catatonic symptoms in an 8Yz-year-old girl, with no observable deleterious side effects. Ortegui et al. (1995) found an 83% response rate in 29 patients, aged

]. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 35:3, MARCH 1996

13 to 16 years, treated with ECT for schizophreniform disorder, impulsive-aggressive disorder, and schizophrenia. Schneekloth et al. (1993) used ECT to treat 20 patients, 18 years and younger, and reported a 65% response rate. The extrapolation of adult criteria and indications for ECT to adolescents may be difficult. Although the mechanism of a therapeutic action of ECT is unclear in adults, there is no reason to believe that this would be different in children and adolescents. The continuity between children and adults who meet DSM criteria for affective disorders has not been established, nor has a consistent group of age-related "associated features" and circumstances that modify the presentation of the illness (Carlson, 1983). Rates of severe depression occurring without comorbid psychopathology appear to be low (Angold and Costello, 1993). Similarly, studies defining "brain damage" in youth have not been done. This unsatisfactory state of the published experience led us to assess our experience with ECT in adolescents, to define better the available indications and to examine the effectiveness. METHOD Through a search of our clinical ECT database established in 1983, we identified 16 young patients, aged 18 or younger, who received ECT between June 1983 and July 1993. Three charts were lost, and we were able to review 13 charts (11 male and 2 female patients). All satisfied the inclusion criteria of age younger than 18 at the time of treatment, with a psychiatric illness, hospitalized, and treated with ECT. From these records we extracted demographic information including birth date, gender, telephone, and address; psychiatric history with stress placed on childhood and developmental history; previous treatments and outcome; and admission and discharge diagnoses. For the treatment course, we recorded electrode placement, number and duration of seizures, type of device, and energy used, as well as adverse effects. The post-ECT treatment, residual symptoms, and discharge arrangement were charted. All patients were treated with a standard adult protocol for ECT, including anesthesia (methohexital), muscle relaxation (succinylcholine), oxygenation, brief pulse currents (MECTA, Thymatron devices), and either unilateral nondominant or bilateral electrode placements. Seizure duration was monitored for motor seizure (cuffed limb) and EEG (Abrams, 1992; American Psychiatric Association Task Force on Electroconvulsive Therapy, 1990; Fink and Johnson, 1982). Patients whose presenting symptoms remitted by the end of the treatment course and who remained asymptomatic 1 month after discharge were termed "responders." The "nonresponders" either had the treatment discontinued, were deemed to have received an "optimum" number of treatments without benefit, or had an exacerbation of their presenting symptoms after a treatment course. With institutional approval, we sent questionnaires to the patients

313

2::

0

~

en tTl

>-

Z 0

'"

tTl

>-:I

:::0 tTl

en

TABLE 1 Demographic and Treatment Data Case 1 2

Age Sex

Admission Diagnosis

Discharge Diagnosis

3 4

16 17 16 16

M M M M

MDD with psychosis MDD Psychosis NOS MDD

MDD with psychosis Bipolar disorder Psychosis NOS Catatonia

5

18

F

Bipolar disorder

Bipolar disorder

6

18

M

Psychosis NOS

7 8 9 10

17 16 17 17

M M M M

Bipolar disorder Catatonia Psychosis NOS Psychosis NOS

11

17

M

Psychosis NOS

12

17

F

Catatonia

Schizophreniform disorder Schizophrenia Catatonia Psychosis NOS Schizophreniform disorder Schizophreniform disorder Bipolar disorder

13

16

M

Catatonia

Bipolar disorder

Note: ECT

=

electroconvulsive therapy; MDD

=

No. of ECT

Electrode Placement

6 16 8

RUL Bil Bil RUL

3

Staring, posturing No catatonia No catatonia Mutism, staring, posturing Posturing, rigidity, waxy flexibility No catatonia

Outcome

Disposition

Responder Responder Responder Responder

Home Home Home Home

with with with with

follow-up follow-up follow-up follow-up

Nonresponder

Home with follow-up

Nonresponder

Day hospital

No catatonia Mutism, staring No catatonia No catatonia

Responder Responder Responder Responder

1 (incomplete) (8 + 10) = 18

RUL+ Bil

17 17 5 10

RUL Bil Bil RUL

20

Bil

No catatonia

Nonresponder

Day hospital Home with follow-up Day hospital Drug rehabilitation program Group home

15

Bil

Responder

Home with follow-up

16

Bil

Elective mutism, posturing, staring Staring, mutism, waxy flexibility

Responder

Day hospital

major depressive disorder; NOS

Bil

Catatonia

=

not otherwise specified; RUL

=

right unilateral; Bil

=

bilateral.

ECT IN ADO LESCENTS

TABLE 2 Comorbidity

DSM-IIl-R code Gender Attenti on-deficit hype ractivity disorder Co nd uct disorder Histoty of substance abuse Previous hospitalization Responders N onresponders

Psycho sis NOS (n = 2)

Schizophreniform Di sorder and Schizophrenia

(n = 4)

Catatonia (n = 2)

298.9 2 males

295.4, 295.9 4 males

295.2 2 males

2

1

1

3

2 2 2

3

None reported None reported 1 2 2 0

o

2

2 2

Bipolar Disorder (n = 4)

Major Depression (n = 1)

296 .6 2 males 2 females None reported None reported 4 4

296.3 1 male

3 1 (incomplete)

None None None None

reported reported reported repor ted 1 0

N ote: NOS = not otherwise specified.

who con sented to follow-up. We assessed their fun ctioning in the com m unity (school , work , relationships, independence) and considered the long-t erm ou tcom e of th e treatment (relapse, drug mai nt enance, and follow-up ). Table 1 summarizes the findings.

RESULTS Diagnosis

Each patient met DSM-III or DSM-III-R criteria for a psychiatric disorder, was hospitalized for at least 3 weeks, and had failed treatment trials of at least two psychotropic drugs. The discharge diagnoses were as follows: one patient had major depressive disorder with psychosis (DSM-III-R diagnosis, 296.3); four patients had bipolar affective disorder (296 .6); two patients had psychotic disorder (298.9); two patients had catatonia (295.2) ; three patients had schizophreniform disorder (295.40); and one patient had schizophrenia (295.9). The catatonic patients did not have any other current psychiatric features besides affective symptoms (Table 2). Childhood psychopathology was reported in 70 % of the patients. Attention-deficit hyperactivity disorder and conduct disorder were reported in the patients with diagnoses of psychosis and of schizophrenia. Nine patients reported a histo ry of substance abuse; 11 had a previous psychiatric hospitalization for the same illness (Table 2). One patient with bipolar affective disorder received ECT the previous year ' at another institution for a depressive episode. Each of the 13 patients had failed trials of neuroleptic, antidepressant , benzodiazepine, anticonvulsant, and

J. AM. ACAD. CHILD AD OL ESC . PSYCHIAT RY, 35 :3, MARCH 1996

milieu therapies. The patients with the diagnosis of catatonia received lorazepam, haloperidol, and chlorpromazine with no response or worsening of their symptoms. Im ipramine, nortriptyline, lithium, and carbamazepine were the ant idepressant s mostly used in patients with prominent depressive symptoms. Systemic Illness

Two patients had a concurrent systemic illness. One had Kleine-Levin syndrome (recurring attacks of morbid sleep, hypersexuality, irritability, agitation, and auditory hallucinations) . One grand mal seizure was reported, and in a previous hospitalization he also had received the diagnosis of posrviral psychosis. A second patient with a history of psoriasis had a depressive mood disorder treated with ECT 1 year prior to the ind ex hospitalization. H e was transferred from another instirution after a 2-month hospitalization during which he received imipramine, haloperidol, chlorpromazine, Huoxetine, and lith ium but did not improve . At our institution, a marked leukopenia developed shortly after a trial of carbamazepine. Eleven patients had normal EEG studies, but the pre-ECT EEG in the patient with the Kleine-Levin syndrome showed a diffuse slowing without focal signs. All oth er pertinent laboratory values were normal; however, a serum Lyme titer was drawn in one pat ient and reported as positive after the first ECT session. This patient was fully investigated, including cerebrospinal fluid analysis, which was nonreactive. A clinical picture of neuroleptic malignant syndrome, with a

315

MOISE AND PETRIDES

creatine phosphokinase level of 2,609 U/L, developed the night after her first ECT session. ECT was subsequently discontinued. Only one patient had psychometric testing performed after his ECT treatment; this showed normal IQ. There was no previous testing to which this result could be compared. ECT Parameters

Electrode placement was bilateral in eight patients and right unilateral in four. One patient began with right unilateral and was later changed to bilateral. The number of treatments ranged from 3 to 20, with a mean of 10.9. For the patient with the positive Lyme titer, the treatment was incomplete since she only received one session. Seizure durations averaged 100 seconds for each treatment. In three patients, seizures longer than 180 seconds persisted on EEG. These prolonged seizures were terminated with intravenous diazepam. These patients had the same response rate as patients with average seizure duration. The response to ECT was independent of electrode placement and number of ECT treatments received. Clinical Efficacy

Ten patients improved with ECT, with remISSIOn of all target symptoms. All the patients had affective symptoms, six had catatonic symptoms, and nine had presented with psychotic symptoms. Those with both affective and catatonic symptoms benefited the most; the catatonic symptoms remitted before the psychotic symptoms. Significant improvements were seen in the patients with the diagnoses of psychotic depression, bipolar affective disorder, and psychosis, and in two patients with the diagnosis of schizophrenia. The two nonresponders had schizophreniform disorder (DSMIII-R diagnosis 295.4) and received 18 and 20 treatments, respectively. Although the psychosis persisted, most of their affective symptoms remitted with ECT, including their suicidal tendencies. Although they did not return to their premorbid state, both were well enough to be discharged to a day hospital. Complications

No complications were reported other than minor and transient cognitive side effects similar to those reported in adults.

316

Follow-up

Eight patients were interviewed by telephone in follow-up. They were all rated as responders. (One patient had relocated overseas and four did not return their consent forms.) The two patients with psychosis (298.9) had returned to school and were attending college at the time of the follow-up. They were asymptomatic and not taking any psychoactive medications 3 years after their ECT treatment. One patient spent 2 years in a drug rehabilitation program after his discharge. The patient with psychotic depression relapsed; 8 months after discharge, while on a regimen of imipramine, he presented with manic symptoms. One patient with catatonia exhibited a syndrome classified as bipolar disorder after 9 months but did not require hospitalization; another patient with a diagnosis of schizophreniform disorder had a chronic course with several hospitalizations. None of the patients reported long-lasting memory difficulties or any experience that would indicate neurological impairment. DISCUSSION

We find ECT to be a useful procedure in the treatment of adolescents with severe psychiatric disorders, a finding that is consistent with recent recommendations (American Psychiatric Association Task Force on Electroconvulsive Therapy, 1990; Schneekloth et aI., 1993). Our patients with bipolar disorder responded well to ECT. In one case, though, the treatment was incomplete; this patient had neuroleptic malignant syndrome, which is now known to respond to ECT. She was treated conservatively; the length of her hospitalization in days was twice as long as for those treated with ECT. No other complications were seen, and in no patients did their condition worsen with ECT. Once the remission began, continuation pharmacotherapy was prescribed for most patients, with apparent success, and usually with the drugs to which they had failed to respond prior to ECT (Devanand and Sackeim, 1991). One patient in our sample with a diagnosis of psychotic depression exhibited mania after 8 months of treatment, and he responded promptly to lithium therapy. Adult outcome and family history studies show that early-onset depressive disorders have a higher rate of conversion to bipolarity than do those of later

J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 35:3, MARCH 1996

E CT I N A D O LE SC EN TS

onset (Strober and Carlson, 1982). This is similar to the experience described by Beiser et al. (1989), who reported that 14% of patients whose first diagnosis was major depressive disorder switched to bipolarity by 9 months and 20% switched by 20 months. When they relapse, patients with a previous response to ECT appear to benefit from retreatment. One example is a 17-year-old who was hospitalized for 2 months because of depression and suicidal ideation. He had received ECT 1 year prior to the index hospitalization. He failed to respond to lithium, imipramine, and fluoxetine; leukopenia developed during carbamazepine therapy and treatment was incomplete. Yet he became euthymic after 16 bilateral ECT treatments. Four years later, he remained asymptomatic on continuation lithium and fluoxetine treatment. He graduated from college with a degree in accounting. The response to ECT in our sample was not related to the duration of the seizures, supporting the finding by Schneekloth et al. (1993), who reported no differences between the improvement rates or the median duration of seizures of the two groups. Guttmacher and Cretella (1988) were concerned about the prolongation of seizures in adolescents. Their experience reflects the low seizure thresholds of children and adolescents and the sensitivity of seizure duration to the energy used to induce the seizure. When induction energies are far above thresholds , seizures are prolonged. Such events are less common when energy dosing is selected according to age. In our sample, three patients had seizures longer than 180 seconds and their clinical response was similar to that of patients with a median seizure duration of 100 seconds, and they did not exhibit adverse effects. None of the patients with personality disorders in the Mayo sample responded to ECT (Schneckloth et al., 1993). This is similar to findings in adult studies (Abrams, 1992). Of our sample of patients, two did not respond to ECT, and one exhibited a prominent concurrent character disorder. One "responder" also had a comorbid character disorder diagnosis. The sample is too small to allow any further conclusion . In the Stony Brook adult ECT data, when compared with the adolescent data, twice as many females as males received ECT, whereas the gender ratio in this sample ' is 5:1, with an overrepresentation of males. The preponderance of males may be multifactorial;

J. AM. ACAD. CHILD AD OLESC . PSYCHIATRY, 35:3 , MARCH 1996

more behavior problems and psychosis are seen in this male population than in females. The treatment of severely mentally ill adolescents is complex and challenging. A recent literature review concludes that there is no evidence from control studies that antidepressant medications , including tricyclics and serotonin reuptake inhibitors, are more effective than placebo in children and adolescents with depressive disorders. (Steingard et al., 1995). Although the possibility of permanent undesirable effects on the developing brain of adolescents cannot be ruled out, we found no evidence of neurological sequelae of ECT in our patients. To our knowledge there is no proof of such effects of ECT in the literature. On the contrary, it is well known that a variety of psychoactive medications may produce permanent effects such as tardive dyskinesia. The adolescents in our sample were markedly ill, considering their past history, lack of response to medications, and comorbidity (Table 2), and yet their symptomatic response to ECT was impressive. Present attitudes in adolescent psychiatry do not favor the use of ECT. That is unfortunate, because the positive experience in the vast majority of reported adolescent patients as well as our own experience is not utilized, and we fear that adolescents who may have successfuloutcomes are deprived of this treatment. In spite of the limitations of this study , which is a retrospective chart review within which the diagnostic information on childhood problems was not systematically obtained and for which 61 % of the sample were available for follow-up, we found ECT to be as effective and as safe in adolescents with severe psychiatric illnesses as it is in adults. We are most comfortable in recommending its consideration in adolescents whose disorders, had they occurred in adults, would be considered candidates for ECT and treated.

REFERENCES Abrams R (1992), Electroconvulsive Therapy, 2nd ed. New York: Oxford Un iversity Press American Psychiatric Association Task Perce on ECT (1978 ), ElectrconvulJive Therapy Task Force Report No. 14. Wa shington , DC : American Psychiatric Association American Psychiatric Association Task Force on Electroconvulsive Therapy (1990), The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training and Privileging. Wa shington, DC :American Psychiatric Association Angold A, Costello EJ (1993), Depressive comorbid ity in children and adolescents: emp irical, theoretical, and methodolog ical issues. Am J Psychiatry 150: 1779-1 791

317

MOISE AND PETRIDES

Baker T (1995), ECT and young minds. Lancet 345:65 Beiser M, Iacono WG, Erickson DH, Fleming JA, Lin TY (1989), The role of social relationships in the course of first-episode schizophrenia and affective psychosis. Am J Psychiatry 146:1456-1461 Bender L (1947), One hundred cases of childhood schizophrenia treated with electric shock. Trans Am NeurolAssoc 72:165-169 Bertagnoli MW, Borchardt CM (1990), A review of ECT for children and adolescents. JAm Acad Child Adolesc Psychiatry 29:302-307 Black DWG, Wilcox JA, Stewart M (1985), The use of ECT in children: case report, J Clin Psychiatry 46:98-99 Campbell JD (1952), Manic-depressive psychosis in children: report of 18 cases. J Nero Ment Dis 116:424-439 Carlson G (1983), Case Studies in Prepubertal Childhood Depression. New York: Spectrum Publications, pp 39-59 Cizadlo BC, Wheaton A (1995), Case study: ECT treatment of a young girl with catatonia. JAm Acad Child Adolesc Psychiatry 34:332-335 Clardy ER, Rumpf EM (1954), The effect of electric shock on children having schizophrenic manifestations. Psychiatr Q 28:616-623 Consensus Conference (1985), Electroconvulsive therapy. JAMA 254:2103-2108

318

Devanand DP, Sackeim HA (1991), Electroconvulsive therapy in the therapy resistant patient. Psychiatr Clin North Am 14:905-922 Fink M, Johnson L (1982), Monitoring the duration of electroconvulsive therapy seizures: cuff and EEG method compared. Arch Gen Psychiatry 39:1189-1191 Guttmacher LB, Cretella H (1988), Electroconvulsive therapy in one child and three adolescents. J Clin Psychiatry 49:20-23 Ortegui JT, Lyford-Pike A, Zurmendi P, Savi G, Flores D, Castro G (1995), Electroconvulsive therapy (ECT) in adolescents and children in private hospitals in Montevideo (Uruguay). Convulsive Ther 1:73 Schneeklorh TD, Rummans TA, Logan KM (1993), Electroconvulsive therapy in adolescents. Convulsive Tber 9:158-166 Steingard RJ, DeMaso DR, Goldman S, BucciJ (1995), Current perspectives on the pharmacotherapy of depressive disorders in children and adolescents. Haru Rev Psychiatry 2:313-326 Strober M, Carlson G (1982), Bipolar illness in adolescents with major depression: clinical, genetic, and psychopharmacologic predictors in a three- to four-year prospective follow-up investigation. Arch Gen Psychiatry 39:549-555 Thompson JW, Weiner RD, Myers CP (1994), Use of ECT in the United States in 1975, 1980, 1986. Am J Psychiatry 151:1657-1661

J.

AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 35:3. MARCH 1996