Recommendations are identified as falling into one of four categories of endorsement. These categories, which are defined at the end of the "Major Recommendations" field, indicate the degree of importance or certainty of each recommendation.
Indications
Before an adolescent is considered for electroconvulsive therapy (ECT), he/she must meet three criteria:
- 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 [MS].
- 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 [MS].
- 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 (1) adequate medication trials are not possible because of the patient's inability to tolerate psychopharmacological treatment; (2) the adolescent is grossly incapacitated and thus cannot take medication; or (3) waiting for a response to a psychopharmacological treatment may endanger the life of the adolescent [MS].
Contraindications
Refer to the "Contraindications" field in this summary for information.
Assessment
Psychiatric Evaluation
The clinician determines that the patient has a condition qualifying for ECT by careful psychiatric and medical evaluation [MS]. The psychiatric evaluation must include a detailed clinical interview, collateral information from parents or other informants, and documentation of target symptoms by using reliable rating instruments, when appropriate. It is essential that the severity of illness be carefully assessed.
Review of Past Treatments
Past treatments should be carefully reviewed and documented. Documentation of previous pharmacotherapy should include the following: each medication prescribed, dosage, duration of each trial, compliance, response, side effects, and response to augmentation strategies where appropriate [MS]. As adolescents often do not fully comply with taking psychotropic medication, medication adherence should be explored by direct methods (i.e., serum or urine drug levels) [CG]. Psychotherapeutic treatments and psychosocial interventions, including but not limited to individual psychotherapy, family psychotherapy, cognitive-behavioral therapy, interpersonal therapy, and hospital milieu, should be reviewed [MS].
Physical Examination and Laboratory Investigation
While there are no absolute medical contraindications for ECT, there may be relative contraindications that require identification prior to ECT. Every patient considered for ECT must receive a comprehensive physical evaluation [MS].
Evaluation of physiological parameters must be completed before the administration of ECT or anesthesia. Appropriate laboratory investigation, required for the diagnosis of a medical condition, must be completed [MS]. Laboratory investigation is dictated by clinical assessment [OP] and may include a complete blood cell count, differential white blood cell count, thyroid function tests, liver function tests, urinalysis and toxicology screen, electrocardiogram, electroencephalogram, and computed tomography or magnetic resonance imaging of the brain. All female patients must have a serum or urine pregnancy test [MS].
Cognitive Assessment
Every adolescent undergoing ECT must have a memory assessment before treatment, at treatment termination, and at an appropriate time after treatment (usually between 3 and 6 months posttreatment) [MS].
Informed Consent
Every attempt must be made to educate the adolescent and parents regarding the procedure, its risks, and benefits [MS]. This education must be provided with sensitivity to racial, cultural, and developmental issues [MS]. Written informed consent for ECT must be obtained from a parent [MS]. In addition, the consent or assent of the adolescent should be obtained [MS]. The adolescent's ability to consent/assent will depend on his/her cognitive maturity and the severity of psychiatric symptoms.
Some states specify a mandatory minimum waiting period (usually 72 hours) between signing the consent document and commencing treatment. During this period consent may be withdrawn. However, parents and adolescents should be informed that they may withdraw consent for ECT at any time [MS].
Familiarity with state and institutional guidelines is necessary to ensure that treatment requirements mandated by the state or the institution are met [MS]. Several states have age-related restrictions regarding the use of ECT.
Second Opinion
Every patient being considered for ECT should receive an independent evaluation from a psychiatrist who is knowledgeable about ECT and not directly responsible for the treatment of the patient [MS]. The psychiatrist providing the second opinion should review the diagnosis, confirm illness severity and treatment resistance, corroborate the advisability of ECT, and review the adequacy of the workup.
Concurrent Treatment
Supportive treatment of the adolescent should continue during the course of ECT. The severity of symptoms and post-ECT monitoring require placement in an inpatient setting [MS]. The patient should participate in the hospital milieu therapy, and support should be offered to the family.
Certain medications are known to interfere with ECT in adults. It is advised that, whenever possible, ECT be administered without concurrent medications [CG]. Some psychotropic medications may be used with appropriate monitoring.
ECT Procedure
The following steps are recommended after the decision to treat with ECT has been made by the physician, the appropriate assessments have been conducted, the independent psychiatrist has provided the second opinion, and informed consent has been obtained.
Anesthesia
Anesthesia should be administered by qualified personnel experienced in treating adolescents [MS]. The anesthetic agent commonly used is methohexital. Muscle relaxation is achieved with succinylcholine. Intravenous atropine or glycopyrrolate may be administered immediately prior to ECT to protect from vagally induced bradycardia and arrhythmias. However, at the present time, there is a lack of consensus as to whether atropine should be administered routinely. Patients are ventilated with 100% oxygen before administration of the electrical stimulation.
Administering ECT
After an overnight fast, the patient is moved to a specially designated area where ECT is administered [MS]. The treatment team should include a psychiatrist, personnel experienced in anesthesia, and nursing staff trained in the use of ECT [MS]. Treatment may begin at either two or three times weekly, with changes to the schedule if the patient experiences a significant degree of confusion [CG].
Unilateral electrode application to the nondominant hemisphere is the preferred method. In a critically ill patient (refusal to eat or drink, severe suicidality, florid psychosis, catatonia), treatment may commence with the bilateral electrode placement. Use of brief pulse and an adequate dosage of electricity are recommended [CG].
Patient Monitoring
Close monitoring should be provided during and after treatment, until the patient is fully recovered from anesthesia. During treatment, monitoring should include observation of seizure duration, airway patency, agitation, vital signs, and adverse effects. After treatment, observation should be provided in a designated recovery area with provision for expert nursing care. Patients should be monitored for at least 24 hours for late seizures that may occur after the ECT session (tardive seizures) [MS]. A neurology consultation should be obtained if recurrent prolonged seizures or tardive seizures occur [CG]. Changing from bilateral to unilateral ECT may be indicated for patients who become manic during the course of treatment.
Adverse Effects
Refer to the "Potential Harms" section of this summary for information.
Patient Management after ECT
Although ECT is an effective treatment of an illness episode, there is no evidence that effective treatment of any given episode prevents future relapse. Therefore, ECT should be regarded as an intervention during the acute phase of the illness. Pharmacotherapy and/or other maintenance treatment (in some cases, maintenance ECT) should be initiated after the last ECT treatment [MS]. However, at this time there is no experience with maintenance ECT in adolescents.
Definitions:
[MS] "Minimal Standards" are recommendations that are based on substantial empirical evidence (such as well-controlled, double-blind trials) or expert clinical consensus. Minimal standards are expected to apply more than 95% of the time (i.e., in almost all cases). When the practitioner does not follow this standard of care in a particular case, the medical record should indicate the reason for noncompliance.
[CG] "Clinical Guidelines" are recommendations that are based on empirical evidence (such as case series, open trials) and/or strong clinical consensus. Clinical guidelines may be expected to apply in approximately 75% of cases. These recommendations should always be considered by the clinician, but there are exceptions to their application.
[OP] "Options" are practices that are acceptable, but not required. There may be insufficient empirical evidence to support recommending these practices as minimal standards or clinical guidelines, or more than one approach demonstrates similar levels of supportive evidence. If possible, these practice parameters will explain the pros and cons of these options.
[NE] "Not endorsed" refers to practices that are known to be ineffective or contraindicated.
