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Ann Marie T. Sullivan, M.D., Acting Commissioner
Governor Andrew M. Cuomo

New York State Office of Mental Health
Guidance on Electroconvulsive Therapy (ECT)
When Considered for Individuals under the Age of 18

July 13, 2009

Background: Electroconvulsive Therapy (ECT) is a vital yet controversial treatment - especially when provided by court order and over objection - which has evoked considerable and important discussion among a broad constituency in New York State. In light of the ongoing debate regarding the use of ECT for individuals under the age of 18, OMH offers this document to clarify its clinical and administrative thinking.

Current medical guidance finds ECT to be a relatively safe and effective intervention, especially when other treatments have proven ineffective for treatment of serious mood and psychotic disorders. Detractors emphasize there are negative side effects of ECT which include memory loss which may not be well reported in the research literature. From a consumer perspective, court-ordered ECT may serve to worsen a long standing concern that mental health care is intrusive and paternalistic, and thus is not person-centered.

Although ECT is recognized as an effective treatment in adults, controversy remains about its use in children and adolescents. Concerns involving efficacy, safety, and acceptability on the part of the youth, the parents, and society have been raised. Issues of consent/assent for youth have also been noted.

Studying efficacy for ECT in children and adolescents has been difficult, principally because of the difficulty in obtaining informed consent/assent and in conducting research with young and vulnerable populations. Therefore, there is relatively limited research that has addressed the issue of ECT in adolescence, and even less has addressed this question in younger children. The American Academy of Child and Adolescent Psychiatry (AACAP) has issued a Practice Parameter for the use of ECT in adolescents that summarizes the research and expert opinion available.

ECT may be beneficial to adolescents with psychiatric disorders, most notably those with unipolar or bipolar mood disorders. Research studies, however, are limited in number and methodological rigor. There are no placebo controlled or non-treatment studies in adolescents. One study found that a small group of youth with bipolar disorder who accepted ECT had improved outcomes compared to youth with bipolar disorder who did not accept ECT.

ECT is used infrequently in adolescents. This is probably due in part to the negative perceptions and emotional reactions that are present in many people when considering ECT, including many psychiatrists and other mental health professionals. Concerns about possible long term effects and the desire not to “experiment” or use “shock treatment” on vulnerable populations who often cannot speak effectively for themselves or give informed consent, complicate the use of ECT in youth. However, research on the perceptions of ECT among adolescent patients and their parents has found that most who underwent ECT and their parents found the treatment less aversive than their psychiatric illness itself, and most patients indicated they would recommend the treatment to others if it had been medically recommended.

States are highly variable in their acceptance of ECT in youth, and in their requirements for assessment prior to administration. Michigan, for example, requires the concurrence of 3 child psychiatrists before ECT is administered; other states require a different number of evaluations and/or have particular age cut offs. The FDA provides no specific regulations regarding the use of ECT in youth. The AACAP Practice Parameter recommends that an independent second opinion of a psychiatrist knowledgeable about ECT be obtained prior to administration. Written consent of the parent(s) should be obtained, with written consent or assent of the adolescent obtained when feasible - recognizing that cognitive immaturity or severity of psychiatric illness may make it difficult to obtain consent/assent from the adolescent.

In summary, ECT has been a last resort treatment that is infrequently used in adolescence because of the relatively limited scientific information about efficacy and safety, negative perceptions associated with its use, concerns around long term sequelae, and difficulty in obtaining informed consent/assent in this group. It is likely that ECT will continue to have very limited use in youth, although it may provide help to some adolescents whose psychiatric conditions, especially mood disorders, are particularly severe, life threatening, or intractable to more commonly used medications or psychotherapeutic interventions.

Due to the limits of current research, ongoing public concern and lack of practice guidelines, OMH has established the following guidance in implementing ECT in New York State.

Specific Guidance to all OMH Facilities:

Before being considered for ECT, an individual age 16-18 must receive a thorough psychiatric assessment by at least two independent board certified child and adolescent psychiatrists. Diagnosis, severity of symptoms and lack of adequate treatment response or adverse response to previous interventions, including medication, must be taken into account. Past history and family history should be reviewed. A medical examination must be performed to rule out medical conditions that are relative contraindications or that require additional medical intervention to address safety issues. A cognitive assessment that includes an assessment of memory must be performed prior to the ECT, shortly after its termination, and then again 3-6 months post treatment.

Although a small number of studies of ECT in the preadolescent age range also suggest clinical benefit, precise guidelines for use in this age range are not available. Because of limited studies of the effects of ECT on youth under age 16, all of the following should be addressed for individuals under the age of 16:

  1. To be considered for ECT, young people under 16 years of age must receive a thorough psychiatric assessment by at least two independent board certified child and adolescent psychiatrists. One should have experience in administering ECT to youth and adolescents and one have experience with other treatment modalities.

    And

  2. Written consent of the parent(s) or legal guardian(s) must be obtained, with written consent or assent of the individual under age 16 obtained when feasible - recognizing that cognitive immaturity and severity of psychiatric illness may make it difficult to obtain consent/assent from the adolescent.

    And

  3. Documentation of adequate dose and duration of psychopharmaceutical trials, including augmentation trials, is present and there is no evidence of having achieved adequate therapeutic response.

    And

  4. A medical examination should be performed to rule out medical conditions that are relative contraindications or that require additional medical intervention to address safety issues.

    And

  5. The facility's JCAHO-approved Ethics Process shall review all documentation including:
    1. adequate dose and duration of psychopharmaceutical trials, including augmentation, have been administered or are precluded by medication side effects;
    2. the proposed treatment is in the patient's best interest;
    3. the patient's stated preference should be considered, but because the individual is under age 16, advanced directive and health care proxy are not useful;
    4. the family has been engaged in considering treatment alternatives;
    5. appropriate attention has been paid to culturally appropriate interventions; and
    6. concerns about the potential negative impact of ECT on the consumer's/patient's future recovery have been addressed, including possible cognitive side effects and, the potential to exacerbate traumatic symptoms, if applicable.

    And

  6. If the facility's JCAHO-approved Ethics Process approves the use of ECT for a specific individual under age 16, then a cognitive assessment that includes an assessment of memory should be performed prior to the ECT, shortly after its termination, and then again 3-6 months post-treatment.