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Modified multiple-monitored Electroconvulsive therapy. (Letters to the Editor).(Abstract)(Brief Article)

To the Editor:

Electroconvulsive therapy (ECT) has been available in the United States for more than 50 years, and its safety in adults is well documented; the mortality rate is approximately 0.000045% (Consensus Conference, 1985). In the 1940s significant numbers of children were first treated with ECT. However, in 1980 only 1.5% of 33,384 ECT patients were younger than 21 (Thompson and Blame, 1987). Reluctance to recommend ECT in youths may be due to a lack of experience rather than the results of systematic studies or untoward outcomes.

A 1997 review of the child literature by Walter and Rey revealed no double-blind controlled studies comparing ECT with other traditional treatments. Nevertheless, ECT has been used to treat many child and adolescent mental illnesses, including bipolar disorder, depression, and schizophrenia. Some reports have found that the efficacy and safety is similar to that in adults (Walter and Rey, 1997), with complications being typically brief in duration: disorientation, memory impairment, excitation, disinhibition, and alteration of seizure threshold.

In contrast to conventional ECT, with one seizure induced per session, MMECT (multiple-monitored electroconvulsive therapy) involves the induction of multiple, closely spaced seizures during a single session. ECT and MMECT are similar in safety and clinical efficacy when total seizure duration is equal (Maletzky, 1986). The advantages of MMECT include shorter treatment duration, fewer hospital days and thus lower costs, and less exposure to the risks of anesthesia. Roemer et al. (1990) found that double-seizure induction offered a more rapid resolution of depressive symptoms; however, these patients also experienced more posttreatment confusion, disorientation, and memory loss. A search of the literature reveals virtually no reports on MMECT in the child and adolescent population. We report on the use of MMECT in an adolescent.

Adam is a 14-year-old white male with a 2-year history of refractory depression and psychosis. His prenatal history and developmental course were unremarkable. At age 4 he had the onset of Tourette’s syndrome and was subsequently placed in emotionally handicapped classes because of his attention-deficit/hyperactivity disorder and behavioral problems. At age 12, Adam became markedly depressed following his parents’ divorce and required psychiatric hospitalization for mutism, refusal to eat (requiring a nasogastric tube for nutrition), and paranoid delusions (he believed that his food was poisoned). Over the next 2 years he remained hospitalized because of paranoia, auditory hallucinations, depressed mood, ritualized touching, vocal and facial motor tics, and little spontaneous speech. Regressed behaviors included encopresis, enuresis, and fecal smearing. Trials of antipsychotics, lithium, benzodiazepines, and antidepressants (tricyclic antidepressants, a monoamine oxidase inhibitor, and fluoxetine) were unsuccessful. Computed tomography head scans, magnetic resonance imaging (MRI) head scans, and multiple electroencephalograms (EEGs) were unremarkable.

Adam was discharged at age 14, but he required readmission shortly thereafter because of a recurrence of symptoms. He believed that people were planning to kill him, was preoccupied with death, and claimed that he received satanic messages from “heavy metal” music, which he listened to constantly. Adam would smear feces on walls, engage in coprophagia, gorge himself with food until he vomited, strip, and publicly masturbate. He also compulsively touched walls and objects as frequently as 100 times each minute.

Results of additional tests (repeated MRI head scan, human immunodeficiency virus test, rapid plasma reagin, ceruloplasmin level, and a lumbar puncture) were negative. The patient’s haloperidol dose was increased to 40 mg, but symptom improvement was minimal. An 8-week course of clomipramine did not improve the repetitive touching or depression. ECT was ultimately recommended. MMECT was used with the hopes that it would more expeditiously improve Adam’s depression and psychotic behavior. The pre-MMECT workup was no different from that for traditional ECT; the American Academy of Child and Adolescent Psychiatry is in the process of establishing guidelines for the use of ECT in adolescents.

Ten ECT treatments with double-seizure induction during treatments 4 through 7 were performed over a period of 3 weeks. The MECTA SR-2 device was used (MECTA Corp., Tualatin, OR). This machine delivers a constant bidirectional square-wave brief pulse stimulus. Standard bifrontotemporal electrode placement was used. Methohexital was used for induction, and succinylcholine was used for muscle relaxation. Both EEG monitoring and the sphygmomanometer “cuff method” for assessment of motor convulsive activity were used to monitor seizure duration. Increasing stimulus strength parameters were necessary for adequate seizure length, with final MECTA settings as follows: pulse width 2.0 milliseconds, frequency 90 hertz, duration 2.0 seconds, current 0.8 amperes. Intravenous caffeine 500 mg was given during the latter three ECT treatments to promote adequate seizure duration. The total seizure duration for the 10 treatments was 699 seconds.

Added: Jul 25, 2006 6:26 pm | Trackback URI |  Email This Post  | Print