Electroconvulsive therapy for adolescents: Make sure it's on the menu

Burdened with stigma and other barriers, electroconvulsive therapy (ECT) may be an underused treatment modality for psychiatric illness in adolescents. Yet, results of a recent review study published by Mayo Clinic psychiatrists looking at two decades of clinic practice and outcome with ECT in this population suggest it should be considered, underlining that it is safe and effective.

"There's a stigma that's still out there — people don't understand how ECT today is virtually a very safe procedure," says John E. Huxsahl, M.D., a child and adolescent psychiatrist at Mayo Clinic's campus in Rochester, Minnesota, and a study author. "But a lot of the public doesn't know that. They see it as a 'One Flew Over the Cuckoo's Nest' sort of barbaric 'shock my patient into seizures,' not the way that ECT is delivered with anesthesia, in an ECT suite with practitioners who do this all the time. Also, children are viewed as a more protected population in terms of research, which then carries over into clinical situations."

The study's findings were published by Dr. Huxsahl and colleagues in the Journal of Child and Adolescent Psychopharmacology in 2016.

The study and its findings

The study reviewed 51 cases of ECT use in adolescents at Mayo Clinic from April 1991 to November 2013. The patients' physicians had recommended ECT for primary mood or psychotic disorders, or catatonia, and the patients received a mean of 9.3 treatments. The Mayo researchers found the conditions of 77 percent of patients treated were much or very much improved based on the Clinical Global Impressions-Improvement scale at treatment conclusion.

Mayo Clinic's experience with ECT in teens

In Mayo Clinic psychiatrists' experience with ECT in an adolescent population, patients needed fewer maintenance medications afterward. Though no self-report ratings scales were utilized to measure tolerance of the procedure, Dr. Huxsahl indicates that by anecdotal report, the children found it acceptable.

"They found it tolerable — probably much more than the kids expected," he says. "It's an unknown for them, so there are fears, such as, 'I have to be under anesthesia, and I'm going to get this shock treatment to my brain.'

"I think that can cause fear in kids when they are facing it for the first time. But I think that a large number of them would say that they had a much less negative experience compared with what they worried about or anticipated."

Side effects for ECT in adolescents were minimal, such as amnesia from the treatment delivery due to creating seizures and thereby interfering with memory formation.

"This amnesia is temporary," says Dr. Huxsahl. "They may never have good recall of what happened while they were receiving ECT — that may never come back — but there's no convincing evidence that it will interfere with their abilities to form new memories and be aware of their life experiences in the future."

Any other side effects seen were due to protective measures for treatment, such as from muscle relaxants, which were almost invariably acute-only effects.

The risk of worsening an adolescent patient's psychiatric illness through use of ECT was almost nil. "In our experience, if ECT doesn't work, it doesn't make things worse; it simply doesn't deliver the benefit that we are looking for," says Dr. Huxsahl.

While hesitant to call ECT lifesaving, he points out that it can alter the disease course.

"In teens, it certainly can disrupt or put into remission severe depression that is associated with suicidality," he says. "We don't know that they would have completed suicide if they had not undergone ECT, however, the morbidity associated with severe depression in teenagers is not small: They can't concentrate; their schoolwork can suffer; they're withdrawn; they lose the ability to enjoy the things they normally enjoy — there's a lot of morbidity associated with it."

Barriers to ECT usage in adolescents

Despite the therapy's safety and efficacy demonstrated in the review study, utilizing ECT with adolescents is not without barriers, such as the following:

Legal stipulations

Several U.S. states do not allow ECT to be administered to minors.

Consent process

In states where ECT is legal, the consent process can be complex. For example, in the state of Minnesota, two other board-certified child psychiatrists have to review the patient's record, interview the patient and agree with a child psychiatrist's recommendation to treat with ECT before proceeding to obtain parental consent.

Stigma

Teen patients' parents oftentimes attach stigma to ECT. Stigma with the adolescent patients themselves varies, indicates Dr. Huxsahl, according to what their parents believe and what their parents say, and it depends on how much the patients have tried to look into it, for example, on the internet.

Putting it into practice

To address ECT stigma in patients or parents, Dr. Huxsahl suggests listening to them and answering their questions, being honest and direct while explaining potential benefits versus side effects.

"Try and answer their questions about what might be inaccuracies about what ECT really is based on how they learned about it and heard about it through the course of their lives," says Dr. Huxsahl. "You have to meet them where they are at, and then go forward and provide them with information."

Dr. Huxsahl does not anticipate ECT will become a high-volume therapy for adolescents. He states that he uses ECT in his practice, but rarely. He also notes small overall numbers for ECT in adolescents reflected in the review study: only 51 cases over a 20-year period. One contributing factor for less ECT use at Mayo Clinic's campus in Minnesota is that many children seen there live some distance away. Having to remain away from home and stay in Rochester for three weeks as an inpatient is a deterrent for parents agreeing to ECT for their children, due to disruption for the family and being far away from family and friends.

Yet, when ECT is used for appropriate patients, Dr. Huxsahl has seen remarkable turnarounds. "We've had kids who've failed multiple — three or four — trials of antidepressants and psychotherapy, and are still severely depressed and virtually nonfunctional. ECT has put them in remission from their depression," he says, "rendering them able to do their schoolwork and normal activities again."

Though Dr. Huxsahl suspects many medical centers may not have a dedicated ECT suite, he believes that child psychiatrists often have access to a facility that does have such a setup.

Beyond an appropriate setting for ECT, the mindset of the treating psychiatrist is critical, per Dr. Huxsahl. "In difficult, refractory, unresponsive depression, consider the possibility of ECT," he says. "Keep it in your treatment options. If you never consider it, you won't do it — you're never going to use a treatment you don't think about. At least 'keep it on the table,' if you will."

For more information

Puffer CC, et al. A 20 year practice review of electroconvulsive therapy for adolescents. Journal of Child and Adolescent Psychopharmacology. 2016;26:632.