نقد و بررسی عمل الکتروشوک درمانی از یک کودک درجه سوم و مرکز روانپزشکی نوجوانان

Abstract Aims and objectives The use of electroconvulsive therapy (ECT) in children and adolescents is a controversial issue. This study was done to examine the pattern and practice as well as the outcome of electroconvulsive therapy administered to children and adolescents admitted to a tertiary care centre. Methodology A 10 year retrospective chart review of all children and adolescents (up to 16 years of age) admitted in the Child and Adolescent Psychiatry Centre, National Institute of Mental Health and Neurosciences (NIMHANS) who had received at least 1 session of ECT was done. Information regarding diagnosis, reasons for prescribing electroconvulsive therapy, details regarding the procedure and outcome variables was collected from the records. Clinical Global Impressions (CGI) scale rating of the severity of illness and improvement seen were done by 2 trained psychiatrists independently. Results 22 children and adolescents received electroconvulsive therapy over 10 years. There were an equal number of boys and girls. All received modified ECT. Most patients who received electroconvulsive therapy were severely ill. Catatonic symptoms 54.5% (12) were the most common reason for prescribing electroconvulsive therapy. It was efficacious in 77.3% (17) of the patients. Electroconvulsive therapy was relatively safe, and most experienced no acute side effects. 68.2% (15) who were on follow up and did not experience any long term side effects due to the electroconvulsive therapy. Conclusions Electroconvulsive therapy has a place in the acute management of severe childhood psychiatric disorders. Further long term prospective studies are required.

Electroconvulsive therapy has established itself as an important treatment modality for a variety of neuropsychiatric disorders in adults (Ueda et al., 2010, Hamoda and Osser, 2008, Fink, 2001 and Chanpattana and Sackeim, 2010). Researchers in India have made notable contributions to the practice of ECT in these disorders (Gangadhar et al., 2010, Viswanath et al., 2013, Phutane et al., 2013 and Thirthalli et al., 2011). However, the literature available on the use of this modality for treatment in children and adolescents is limited (Rey and Walter, 1997 and Shoirah and Hamoda, 2011). To highlight this point, in a survey of the practice of electroconvulsive therapy in Asia, only 6% of the patients who received this modality were less than 18 years of age (Chanpattana et al., 2010). Most of the literature available on this population is based on case reports or series and has supported the view of ECT as an effective form of treatment, especially in serious mental illnesses (Rey and Walter, 1997, Hegde et al., 1997, Russell et al., 2002, Consoli et al., 2012, Moise and Petrides, 1996 and Grover et al., 2013). This paucity of literature in the child and adolescent population could reflect the fact that a number of psychiatrists are circumspect about prescribing electroconvulsive therapy for clients in this particular age group due to a lack of adequate training and/or experience. In addition, there is a lack of systematic evidence of the effect of electroconvulsive therapy on the developing brain (Ghaziuddin et al., 2001a and Ghaziuddin et al., 2001b). The nature of discourse on the topic of electroconvulsive therapy in the media has meant that the general public and policy makers regard its continued use critically, with attitudes that are more often skewed by hyperbolic suspicions rather than reasoned concerns (http://www.news-medical.net/health/Electroconvulsive-Therapy-Patient-Experience.aspx; Kothari and Chatur, 2012 and Andrade et al., 2010). However, most adolescents – and parents of adolescents – who were treated with electroconvulsive therapy report that not only was the illness experience more arduous than the treatment itself, they would recommend it to others if it was prescribed by their doctor (Walter et al., 1999a, Walter et al., 1999b, Walter et al., 1999a and Walter et al., 1999b). The new Mental Health Care Bill (2013), drafted by the Department of Health and Family Welfare, Government of India, places the use of electroconvulsive therapy in minors under prohibited procedures (Mental Health Care Bill, 2013). Prohibiting the use of electroconvulsive therapy in minors amounts to denying a potentially lifesaving treatment option in those afflicted with most severe forms of mental illnesses. Not only is this a stance in contravention to the evidence available so far, albeit limited, but this may potentially result in prolongation of severe morbidity and possibly greater mortality. The short and long term adverse effects of this treatment modality have often been a point of concern and controversy. Studies have shown that while most patients have no serious side-effects, a small minority experience prolonged seizures, headache, nausea, vomiting, and post-ECT delirium (Grover et al., 2013 and Mental Health, 1999). Apprehensions regarding the effect of electroconvulsive therapy on cognitive function have been addressed in a few studies which show that cognitive functions returns to baseline levels after treatment and are similar to psychiatric controls (Cohen et al., 2000a, Cohen et al., 2000b, Ghaziuddin et al., 2001a and Ghaziuddin et al., 2001b). The National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore has an exclusive child and adolescent psychiatry service and acts both as a primary and a tertiary care referral centre, not only for patients from surrounding states but across the country. We studied the frequency and indications for the use of ECT, along with the clinical profile of patients, effectiveness and incidence of adverse effects associated with this modality of treatment. We also collected information where available about the outcome (clinical and functional) in those who received electroconvulsive therapy in their adolescence.

Electroconvulsive therapy is a safe and effective procedure in the treatment of certain serious mental illnesses. Long term follow up in those clients who could be contacted did not reveal any side effects due to the procedure. The use of this treatment modality by psychiatrists in children and adolescents has always been cautious. Safeguards to prevent and minimise adverse effects especially in the child and adolescent population is necessary. More training and expertise in the use of this modality needs to be developed. However, prohibition of its use may not be a step forward. EEG monitoring and consensus building between two psychiatrists should be encouraged. Electroconvulsive therapy has an important role in the treatment of serious mental illnesses in children and adolescents.