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Page 1 of 4 Baldwin, Steve; Jones, Yvonne
Vol. 33, Adolescence, 09-22-1998, pp 645(1).
Few treatment approaches have caused as much controversy as electroconvulsive therapy (ECT). Since its first documented use in the 1940s (Cerletti, 1956; Slater, 1951), there has been ongoing discourse about its effectiveness. This debate has generated much heat but insufficient light to permit conclusive recommendations about the limits of its application.
In the 1950s, ECT was viewed by many physicians as harm-free and potentially useful for a wide range of disorders and client populations. It was considered helpful in the treatment of affective disorders, in particular chronic depression - "cases in which the clear-cut, dynamically understandable and approachable neurosis has been overlaid by a serious depressive affect" (Gallinek, 1952). In the treatment of neurotic disorders, ECT was viewed by some psychiatrists as of decisive benefit; it often marked a turning point from therapeutic failure to perceived therapeutic success. Other clinical problems, such as anorexia nervosa, were also considered potentially resolvable by ECT. Similarly, client populations with schizo-affective disorders, narcotic addiction, and obsessive-compulsive behavior were included in many early clinical trials. The literature on ECT with minors was sparse, although some children and young adults were included in treatment populations (e.g., Gallinek, 1952).
ECT research and practice during the 1960s was characterized by efforts to understand how it produced results, with further attempts to specify optimum client populations (Abrams & Fink, 1969; Mendels, 1967; Sargent & Slater, 1963). Although there was more interest in the establishment of experimental designs to evaluate the effectiveness of ECT, many of these were unsophisticated trials with poor methodologies, producing inconclusive results. Most studies were based on ad hoc variations of normal clinical practice.
In the 1970s, increasing concern in the mental health field about client rights prompted a series of surveys and studies about ECT and its applications. This closer examination of ECT was associated with a narrowing of clinical focus to specific disorders with more discrete populations.
The seminal task force report on ECT in Massachusetts influenced a generation of clinicians. It found that "most authoritative publications appear to be in agreement that symptoms associated with the depressed phase of manic-depressive illness or involutional melancholia are treated most effectively by ECT" (Frankel, 1973). Nonetheless, the report noted continuing disagreement in the field with regard to the use of ECT with adults who had schizophrenia, its combined use with psychotropic drugs, and questions about subsequent brain damage. The use of ECT in childhood and adolescent disorders similarly was viewed as an area of unresolved debate.
An analysis of responses to the task force questionnaire (from which the report was written) indicated that all respondents assigned some value to ECT in the treatment of severe depression, especially when risk for suicide was present.
Some practitioners stated that it would be appropriate to consider ECT when psychotherapy or use of medication had been unsuccessful, or when a poor response to other therapies had rendered the person nonfunctional. Most respondents indicated the need to complete extensive pretreatment examinations (typically including an ECG, a chest x-ray, an EEG, a spine x-ray, a brain scan, and additional neurological tests) to determine the suitability of ECT for individual clients. About a third of the respondents (17 of 56) emphasized the inadvisability of ECT with children or adolescents, or to persons with neurotic/addictive behavior problems. Other contraindications were noted, and: for patients who are angrily dismayed or frustrated by disappointing events in their lives but who are still able to function adequately in other spheres, in whom there is no evidence of recognizable psychosis or serious suicidal thought or action, skilled psychotherapy should be energetically and adequately administered, with or without the assistance of medication. ECT is not the treatment of choice in such conditions, as it can neither remove nor resolve life-situational problems (Frankel, 1973).
With regard to adverse effects of ECT, the task force report focused on memory loss. Although no respondents offered incontrovertible proof of deterioration, nearly 18% (10 of 56) indicated irrecoverable gaps in memory, intellectual deterioration, or blunting in individual clients after multiple administrations. In contrast, other practitioners claimed never to have seen adverse effects, despite extensive use of ECT.
Concerning legal and ethical considerations, there was widespread agreement about the need for informed consent prior to ECT. A "treatment request," describing the procedure and stating that all questions had been answered, should be read and signed. If the person was unable to grant consent, the consent of a relative or guardian should be obtained; commitment laws could also provide the legal machinery for an in lieu agreement.
The task force was unanimous regarding the treatment of young persons: "administration of ECT to children who have not yet reached puberty has no established usefulness and that therefore such treatment on a routine basis cannot be justified" (Frankel, 1973). However, if ECT was offered as a treatment procedure for prepubertal children, then (1) it must be explained to parents/guardians that effectiveness of ECT for psychiatric disorders in preadolescent children is not proven, and that such use is not generally accepted; (2) that following a rigorous investigation of the case, explicit indications for an experimental trial should be recorded, and that the quality of the study should ensure publishable results; and that (3) it would be prudent before proceeding to have concurrence by a colleague from another hospital, providing additional clinical justification for the experimental use of ECT with a particular child. The problems posed by diagnosis and treatment of persons aged 13 to 16 prompted unanimity that consultation with a colleague be encouraged when ECT is contemplated. Many respondents were in favor of recommending mandatory consultation with a colleague in another hospital before administration of ECT to young clients.
The report also recommended conducting unbiased follow-up studies to evaluate the effectiveness of ECT. In addition, all persons who administer it should familiarize themselves with other treatment methods, allowing long-term comparative studies. The report concluded: "we believe that the onus is now on those whose views differ markedly from the recommendations expressed here to report their findings" (Frankel, 1973).
In the United Kingdom, ECT with children and adolescents generally was viewed during the 1970s as an unusual but not exceptional treatment. It was available as a treatment option to "control an acute psychotic or depressive illness," and was considered "if all drug treatments have failed after proper and prolonged use to control the illness" (Frommer, 1972). In some psychiatric clinics, it was viewed as an option for adolescents who were persistently suicidal and was made available as an inpatient treatment, prior to outpatient administration. As in treatment with adult populations, ECT was continued as long as the client showed improvement. Some physicians recommended that ECT should not be withheld on the basis of age alone, but rather should be a pragmatic treatment decision following nonresponse to pharmacotherapy (Frommer, 1972).
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