Using Other Biologic Treatments: Electroconvulsive Therapy, Transcranial Magnetic Stimulation, Vagus Nerve Stimulation, and Light Therapy

GARRY WALTER

NEERA GHAZIUDDIN

KEY POINTS

Electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), vagus nerve stimulation (VNS), and light therapy are treatments quite different from each other in nature and scope.
The use of VNS and TMS in young persons should at this point be deemed experimental and for cases that are severe and have not responded to any other type of treatment.
Light therapy is considered one of the first-line treatments for patients with seasonal affective disorder (SAD).
Although these treatments may prove beneficial for young people with depression, many patients and families are apprehensive about their use (with the possible exception of light therapy). These are some of the key questions for clinicians to consider:
- Is the diagnosis for which the treatment is to be given accurate, thus justifying use of the treatment?
- Have adequate trials of pharmacotherapy and psychotherapy been undertaken? (This question is less relevant for SAD and light therapy.)
- Have the potential benefits and risks of treatment been clearly conveyed to young patients and parents prior to commencement? (This is particularly important, because the evidence base for these treatments is often not strong.)
- How should these treatments be integrated with other treatments (e.g., medication, psychotherapy) while being used and after cessation?
Clinicians need to be familiar with the local legal requirements for the administration of ECT, which vary widely between jurisdictions. For example, after a parent or a guardian has consented, some U.S. states require that several child and adolescent psychiatrists concur about the need for ECT before it is administered.
Because of the strong, often extreme, emotions this treatment can generate, the decision about the need for ECT should not be made lightly and informed consent processes must be carefully followed.
Neuropsychological assessment should be completed prior to ECT (unless the patient is too ill or disorganized), on completion of the course, and 3 to 6 months later to evaluate potential cognitive deficits.
Side effects of ECT are typically mild and transient. These may include short-term memory disturbance, headache, muscle and joint pain, drowsiness, post-ECT confusion, nausea, and disinhibition.

Introduction

Although pharmacotherapy (Chapter 6) is the most commonly employed biologic treatment for depression in young people, a range of other biologic therapies have been used or show potential. This chapter focuses on electroconvulsive therapy (ECT)—because of the much larger number of studies and longer history of use when compared with the other treatments described—but we also briefly consider transcranial magnetic stimulation (TMS), vagus nerve stimulation (VNS), and light therapy. This chapter should also be read in conjunction with Chapter 16 on treatment-resistant depression. Table 7.1 summarizes the evidence for effectiveness, taking into account not only the scarce data from treatment studies in adolescents but also by extrapolating information from adult studies.

TABLE 7.1 SUMMARY OF NONPHARMACOLOGIC BIOLOGIC TREATMENTS FOR DEPRESSION IN ADOLESCENTS

Treatment	Earliest Published Report as Psychiatric Treatment in Young Persons	Controlled Study(ies)	Quality of Overall Evidence	Strength of Recommendation	Comments
ECT	19421	No	**	[check mark][check mark]	Relatively large number of published reports; limited data in preadolescents; controlled trials unlikely to be conducted.
TMS	20012	No^a	*	[check mark]	Few studies, but early results promising.
VNS	No studies	No	No studies	[check mark]	Experimental treatment. No studies in young people with psychiatric illness.
Light	19863	Yes	*	[check mark][check mark]	Data limited, but includes therapy controlled trial reporting positive results.
ECT, electroconvulsive therapy; TMS, transcranial magnetic stimulation; VNS, vagus nerve stimulation.
*Multiple high-quality scientific studies with homogeneous results; At least one relevant high-quality study or multiple adequate studies; *Expert opinion, case studies, or standard of care.
[check mark][check mark]Useful and effective; [check mark][check mark]Weight of evidence/opinion is in favor; [check mark]Usefulness not established.
^aThe reports by Walter et al. 2 and Loo et al.4 include data extracted from controlled studies and data from the first two subjects in a controlled trial, respectively.

ELECTROCONVULSIVE THERAPY

ECT, one of the oldest treatments in psychiatry, entails the production of a brief passage of current through the brain via electrodes placed on the scalp, resulting in a generalized seizure. Its use in young people was first described in the early 1940s by Heuyer and colleagues,1,5 who concluded that ECT is a safe procedure and often effective in children and adolescents with melancholia. Soon after, however, the use of ECT in the young appeared to decline, probably owing to apprehension about potential (but unproved) harmful effects and the advent of psychotropic drugs.6 Negative perceptions have contributed to ECT being outlawed for children and adolescents in several U.S. states. Adolescents today constitute about 1% of all patients treated with ECT.

EFFECTIVENESS AND INDICATIONS

Several reports over the past 20 years6,7,8,9,10 have suggested that ECT is effective for the treatment of unipolar and bipolar disorders in adolescents. However, it is noteworthy that, to date, there has not been a single randomized controlled trial (RCT) in this age group. A comprehensive review of ECT in children and adolescents, published in 1997,6 examined 60 reports and emphasized that the overall quality of studies was poor. It warrants digressing to note that ECT may also be effective in the
treatment of adolescents with schizoaffective disorder, schizophrenia, other psychotic disorders, catatonia, and neuroleptic malignant syndrome.

The response rate to ECT among adolescents is 60% to 80% for mood disorders (and somewhat lower for psychoses),6 based on case series. Given this situation, it is necessary to extrapolate data from adult research, which has produced similar results, although adolescents may not necessarily respond in the same way as adults. ECT is the most effective treatment available for adult patients with severe depression, producing significant or complete symptom remission in <70%. Data from 90 RCTs11 in adults with depressive illness of varying severity suggest the following:

Real ECT (that is, where an electric current is applied) is more effective in the short term than sham ECT (when no electric current is applied).
Stimulus parameters have an influence on efficacy.
Bilateral ECT is more effective than unilateral ECT.
Raising the electrical stimulus above the individual’s seizure threshold increases the efficacy of unilateral ECT at the expense of increased cognitive impairment.
In trials comparing ECT with pharmacotherapy, ECT produced greater benefit than the use of certain antidepressants (although the trials were of variable quality).
The combination of ECT with pharmacotherapy was not superior to ECT alone.

Comorbid psychiatric disorders, including personality disorder, are not a reason to deny ECT, although response may be less consistent in such patients. For example, in one study,12 there was a 27% response rate in adolescents with both major depression and personality disorder, compared with a 71% response rate in adolescents with major depression alone. Response rates and indications for ECT are similar in adolescents and adults.13,14

In general, after successful ECT, individuals must continue pharmacologic or another sort of treatment to maintain the improvement. Although ECT is often highly effective for the treatment of an index episode of depression, the long-term outcome is variable. For instance, following ECT treatment, patients may remain symptom free for an extended period of time but may experience recurrence and, in the longer term, they may not differ significantly from psychiatric controls in areas of social or school functioning. Taieb et al.15 examined a small group of adolescents with psychotic depression or bipolar disorder over 5 years and found that school functioning was more likely to be associated with illness severity than type of treatment received.

The American Academy of Child and Adolescent Psychiatry16 suggests that ECT may be considered for a child or adolescent who suffers from a severe psychiatric disorder (unipolar or bipolar mood disorder, or other condition), who may be resistant to or unable to tolerate conventional treatment and/or whose safety is compromised when waiting for response from such treatment (e.g., the patient is not eating or drinking or is acutely suicidal). The United Kingdom’s National Institute of Clinical Excellence (NICE) recommends that ECT should only be considered for adolescents with very severe depression and either life-threatening symptoms (such as suicidal behavior) or intractable and severe symptoms that have not responded to other treatments.17

ECT is rarely used in prepubertal children, as noted earlier, and NICE does not recommend using ECT for children <12 years. However, encouraging results have been observed in this age group when ECT has been used for serious and/or refractory disorders. For instance, Russell et al.18 described a prepubertal child who was successfully treated with ECT for severe depression and catatonic features. Esmaili and Malek19 described a 6-year-old girl with similar clinical features and outcome.

SIDE EFFECTS

Side effects of ECT are typically mild and transient and not dissimilar to those reported for adult patients. These may include headache, muscle and joint pain, drowsiness, post-ECT confusion, nausea, memory complaints, and disinhibition.6,12 Disturbance of short-term memory is a well-known side effect of ECT, with greater disturbance of impersonal than autobiographical memories.20 Advances in treatment technique over the past decade have enabled a reduction of adverse cognitive effects of ECT. Nearly all ECT devices currently used deliver a lower current, brief-pulse electrical stimulation, compared with the earlier machines that had sine wave output. With a brief-pulse electrical wave, a therapeutic seizure may be induced with as little as a third the electrical power of the older method, thereby reducing the potential for confusion and memory disturbance.

Cognitive Effects

To date, only two studies have focused on the cognitive effects of ECT in adolescents. The first, by Cohen et al.,21 compared 10 adolescents with severe mood disorders treated, on average, 3.5 years earlier, with controls. All patients, except one who was mildly hypomanic, were in remission at the time of follow-up assessment. Objective tests did not reveal significant group differences for short-term memory, attention, new learning, and objective memory scores. It was also found that poorer cognitive performance was significantly associated with greater psychopathology. The second study, of 16 adolescents treated with ECT, was by Ghaziuddin et al.22 Complete recovery of cognitive functions with return to pre-ECT functioning was noted at the second post-ECT testing (8.5 ± 4.9 months after the last treatment). A large body of evidence in adult patients shows that memory loss, anterograde, and, more commonly, retrograde, can occur.20 Usually these improve after a few weeks and months, but some amnesia can persist for longer.

Prolonged Seizures

Prolonged seizures (>180 seconds) during treatment and, rarely, spontaneous seizures after full recovery from anesthesia have been reported. Guttmacher and Cretella23 described prolonged seizures in two of their four patients, and Moise and Petrides8 in 3 of 13 patients. The exact cause of these seizures or their clinical relevance is not fully understood at this time. However, lower-seizure threshold among adolescent patients is a likely contributing factor.

Structural Abnormalities

Fears that ECT may cause gross structural brain pathology have not been supported by decades of methodologically sound research in both humans and animals.24 Nevertheless, at present there are no data specific for children or adolescents regarding the effect of ECT on brain structure.

Death

The literature on ECT use in young people has reported only one fatality, a 16-year-old girl with neuroleptic malignant syndrome (NMS) who died 10 days after her last ECT.25 However, this outcome was possibly related to continued administration of a neuroleptic medication, despite her NMS, rather than ECT per se. Adult data show death rates of about 1 per 25,000 treatments, which is similar to the death rate of general anesthesia.

LEGISLATION

The use of ECT has been legislated in many jurisdictions, particularly when administered involuntarily to patients unable to give informed consent and to juveniles, but legislation varies considerably. For example, California prohibits the use of ECT for children <12 years. Minors between 12 and 15 years of age may only receive ECT if, in addition to the other provisions authorizing ECT, the circumstances are life threatening and the unanimous opinion of three child psychiatrists appointed by the mental health commissioner is in favor of ECT. In Texas, amendments to the legislation in 1993 resulted in the prohibition of ECT in patients <16 years. In France, Iceland, Latvia, the Netherlands, Norway, Portugal, Romania, Spain, and Turkey, only the written consent of the nearest relative or the legally appointed guardian is required. ECT is prohibited in some cantons in Switzerland, but patients can travel to different cantons to receive treatment.

ATTITUDES TOWARD ELECTROCONVULSIVE THERAPY

Studies of persons who received ECT as adolescents and their parents26,27,28 suggest that the majority had very positive views about the treatment. For example, young patients would have it again if required, they would recommend it to others, and they rate the underlying illness, for which ECT was given, worse than the treatment. Such positive attitudes are reassuring for would-be recipients of the treatment, and they help offset negative views about the treatment in the wider community.

Only gold members can continue reading. Log In or Register to continue