ECT in children and adolescents

Transcription

1 ECT in children and adolescents Adi Sharma MD MRCPsych PhD Clinical Senior Lecturer & Hon Consultant in Child & Adolescent Psychiatry National Adolescent Bipolar Service 1 Conflicts None relevant to this presentation 1

2 Frequency of use Talk Indications for use Side effects Prognosis Consent, capacity and legal considerations Patients, carers & clinicians views Case vignettes Frequency of Use ElectroConvulsive Therapy Accreditation Service (ECTAS) reports % of ECT use across the British Isles excluding Scotland, which collects its own data but records those aged under 30 as one age category) (SEAN, 2016) 1 case in cases in cases in May underestimate as not all ECT clinics are ECTAS registered, or responded to the ECTAS questionnaires. Cresswell and Hodge, 2013; Cresswell et al, 2014; Buley et al, 2015; Buley et al,

3 Indications for use Mood disorders (unipolar and bipolar) Psychotic disorders Catatonia and Neuroleptic malignant syndrome (NMS) Case reports for severe self-injurious behaviour (SIB) occurring in the context of significant Intellectual Disability (ID) and/or Autism Spectrum Disorders (ASD), intractable seizures and pervasive refusal syndrome (Ghadziuddin & Walter, 2013; Griesemer et al, 1997; Shin et al, 2011; Carroll, 2012) Mood disorders Mood disorders: most common indication for paediatric ECT Majority of adolescents treated with ECT have severe depressive symptoms and multiple areas of functional impairment (Ghadziuddin & Walter, 2013) Limited evidence of efficacy of ECT being used successfully to treat mania (Cohen et al, 1997) Usually treatment resistance, with several failed trials of medication, often in combination with psychotherapy. 3

4 Canadian study compared treatment outcomes of inpatient adolescents with bipolar disorder offered either ECT (16 patients accepted ECT) or standard care (6 patients refused ECT) (Kutcher & Robertson, 1995) Patients given ECT had their hospital admission approximately halved in comparison to those receiving standard care (73.8 vs 176 days) Systematic review showed improvements in 63% of patients with depression and 80% of patients with mania (Rey & Walter, 1997) Remission improved using continuation ECT in combination with other treatment as appropriate. No consensus on preferred electrode placement for optimal response but there appears to be a preference for bilateral placement (Ghadziuddin & Walter, 2013) Vignette 16 year old female 6 month history of depressive symptoms Past 1 month restricting fluid and food Past 1 week seen talking to self by nursing team on unit Been tried on 2 SSRIs and Venlafaxine 4

5 Treatment ECT 6 treatments Mood lifts as reported subjectively and objectively Appears quiet, little conversation What next? Psychotic disorders Studies comparied adolescent patients with psychotic disorders to adult cohorts or a matched group of adolescents not receiving ECT (Bloch et al, 2001; Stein et al, 2004; Bloch et al, 2008; de la Serna et al, 2011) Found ECT effective in adolescents with psychotic disorders but less so than for affective disorders (Bloch et al, 2001; Stein et al, 2004; Rey & Walter, 1997) Reported to be generally safe in adolescents no long-term cognitive impairment (de la Serna et al, 2011) Appears more effective for positive, affective and catatonic symptoms of psychosis and less effective (if at all) for negative symptoms (Ghadziuddin & Walter, 2013) 5

6 ECT generally used as an adjunct to conventional psychopharmacological treatment rather than a standalone treatment for psychotic disorders. Resistance to antipsychotics, including clozapine, is the commonest reason for using paediatric ECT in adolescents with psychoses (Bloch et al, 2008; Baeza et al, 2010; de la Serna et al, 2011; Consoli et al, 2009) ECT may also be indicated for intolerance to antipsychotic medication, florid psychosis with severe agitation causing risk to life, or in pregnancy, where it is deemed safer than the use of psychotropics (Ghadziuddin & Walter, 2013; Shiozawa et al, 2015) Early adjunctive ECT with pharmacotherapy may speed treatment response & reduce hospital stay (Zhang et al, 2012) Catatonia Seen in affective or psychotic disorders or may exist as an independent diagnosis as reflected by the addition of Catatonia NOS to the DSM 5 (APA, 2013) 12 17% of adolescents and young adults with ASD have features of catatonia (Billstedt et al 2005; Wing & Shah, 2000) ASD-associated catatonia, there are no RCTs, so management is based upon case reports and evidence regarding treatment of neurotypical adults (Ghadziuddin & Walter, 2013). 6

7 Catatonia Significant symptom relief after ECT, without altering the underlying ASD pathology Fequency of ECT needed to improve catatonia symptoms may be more than for depression i.e. >2 sessions/week (Ghadziuddin & Walter, 2013) Case Vignette 12 year old with moderate to severe ID 2 week history of catatonic stupor Admitted to Paediatric ICU Investigations NAD ECT Considered 7

8 ECT Attempted twice (Mon/Thurs) same week No Seizure Why and what next Catatonia For patients prescribed benzodiazepines for catatonia, the effect on seizure threshold should be acknowledged 8

9 Neuroleptic Malignant Syndrome Case reports of paediatric NMS being treated successfully with ECT (Tanidir et al, 2016; Araujo et al, 2013; Steingard et al, 1992, Ghaziuddin et al, 2002) Contrasting reports of ECT being unsuccessful in reducing the course of NMS (Silva et al, 1999) Suggested that variation in response may be related to the underlying cause of NMS with those taking atypical antipsychotics appearing to respond more favourably than those taking typicals (Neuhut et al, 2009) Side effects Literature regarding side effects of paediatric ECT relates only to adolescents, not children Adolescents more likely to experience headaches and prolonged seizures than older people (Ghadziuddin & Walter, 2013) May be related to a lower seizure threshold in younger people so use propofol as the anaesthetic agent No reported deaths related to paediatric ECT (Ghadziuddin & Walter, 2013) 9

10 Memory Impairment Subjective memory impairments ranges from less than 5% to 50% of adolescent (Kutcher & Robertson, 1995; Cohen et al, 1997) 3 studies reported no objective residual memory impairment several months following the final ECT session (Ghadziuddin et al, 2000; de la Serna et al, 2011; Cohen et al, 2000) Sole study assessing long-term cognitive effects studied 10 adolescents an average of 3.5 years (+1.7years) after ECT and did not demonstrate any measurable anterograde memory deficit (Cohen et al, 2000) Other side effects Nausea, vomiting, muscular pain and confusional states been reported but are transient (Cohen et al, 1997; Walter & Rey, 1997; Ghadziuddin et al, 1996) ECT induced mania or hypomania may occur If it does, continue ECT but take appropriate precautions to maintain safety and consider a mood stabilizer after ECT (Angst et al, 1992) 10

11 Prognosis Influenced by multiple factors including; primary indication for ECT, comorbid diagnoses, pre-morbid functioning and presence of somatic symptoms Comorbid diagnoses, often anxiety disorders, may respond well to ECT but often require longer courses and ongoing additional therapeutic interventions (Ghadziuddin & Walter, 2013) Better premorbid functioning more likely to achieve complete remission of symptoms (Ghadziuddin & Walter, 2013) Younger age at first presentation to psychiatric services may predict poorer outcomes (Ghadziuddin, 2011) ID has no effect on response to paediatric ECT (Ghadziuddin, 2011) Consent, capacity and legal considerations: England and Wales Paediatric ECT cannot be given without approval from a Second Opinion Appointed Doctor. Where the child or adolescent is subject to MHA the relevant treatment section would apply. If not subject to MHA and unable to provide consent (i.e. a 16 or 17 year old lacking capacity or an under 16 found not to be competent) the legal authority to give ECT needs to be clarified. Whilst a person with parental responsibility is able to consent to treatments that fall within the zone of parental control, ECT is likely to fall outwith this (Department of Health 2015) At present there is no case law relating to use of ECT in these circumstances. 11

12 Consent, capacity and legal considerations: Scotland Paediatric ECT can only be given to informal patients who are deemed capable and give written consent, or, in those deemed incompetent to consent, written consent must be obtained from someone with parental responsibility and an independent Designated Medical Practitioner (DMP) must approve this (Scottish Executive, 2005) Either the Registered Medical Officer (RMO) recommending ECT or the DMP must be a child specialist. Paediatric ECT can be given to detained patients without the need for approval from a DMP if the patient is capable and provides written consent (Scottish Executive, 2005) Consent, capacity and legal considerations: Northern Ireland Currently a lack of specific guidance regarding legal authority to treat with paediatric ECT When it comes into force, the Mental Capacity Act (Northern Ireland) 2016 will apply to all persons age 16 and over. So no specific requirements about ECT for year olds. 12

13 Consent, capacity and legal considerations: Republic of Ireland Not permissible to administer paediatric ECT to detained patients without approval of the District Court (Mental Health Commission, 2006) No specific guidance regarding informal paediatric patients. Patients & carers views An Australian telephone survey of adolescents who had received ECT and later of their parents found generally positive views (Walter et al, 1999) 50% of the adolescents thought ECT had been helpful and 69% would have it again. Only 8% felt ECT was worse than the illness itself. 86% of parents would support using ECT again and 79% would have ECT themselves. Later French and Spanish studies had similar findings (Taieb et al, 2001; Flamarique et al, 2015) 13

14 Clinicians views UK study surveyed child psychiatrists views in 3 different age groups: <12 years, years and >17 years (Parmar, 1993) Clear differences in the acceptability of ECT for the various age groups; e.g. for psychotic depression, it was felt to be unhelpful in 42%, 19% and 5% of the respective age groups. 79% of respondents had never used paediatric ECT and 22% of these stated it was because of lack of evidence. Other studies carried out in Australia, New Zealand and the USA report similar hesitance to use paediatric ECT amongst child psychiatrists (Walter et al, 1997; Ghaziuddin et al, 2001; Walter & Rey, 2003) Summary AACAP 2004 Practice Parameter for Use of Electroconvulsive Therapy with Adolescents (AACAP, 2004) outlines 3 minimal standard criteria: Diagnosis: severe, persistent, major depression or mania + psychotic features, schizoaffective disorder, or, less often schizophrenia. May be used to treat catatonia & NMS. Severity of symptoms: severe, persistent & significantly disabling. May include life-threatening symptoms such as refusal to eat or drink, severe suicidality, uncontrollable mania, and florid psychosis Lack of treatment response: failure to respond to at least 2 adequate trials of appropriate psychopharmacological agents accompanied by other appropriate treatment modalities. Both duration and dose determine the adequacy of medication trials. 14

15 ECT may be considered earlier when a) adequate medication trials are not possible because of intolerance of psychopharmacological treatment, b) the adolescent is grossly incapacitated and thus cannot take medication, or c) waiting for a response to a psychopharmacological treatment may endanger life Recommends every adolescent must undergo age-appropriate memory assessment before treatment, at treatment termination and at appropriate time after treatment (usually between 3-6 months post-treatment) (AACAP, 2004) Side effects are systematically assessed with an appropriate side effect scale before the initiation of ECT and at treatment completion and that side effect evaluation should occur after every treatment but doesn t specify particular tools (AACAP, 2004) Seek specialist legal advice before considering administering paediatric ECT As consent and ethical concerns with RCT, plan prospective studies which focus on follow up with regards to long term symptom remission and cognitive side effects using established methodology of the RCPsych Child and Adolescent Psychiatry Surveillance System (Smith, 2016) 15

16 Acknowledgements Dr. Rosalind Oliphant and Dr Eleanor Smith Northumberland Tyne and Wear NHS Foundation Trust Prof Nicol Ferrier and Dr Jonathan Waite 16