The November 2014 issue of the British Journal of Psychiatry included a review of a book called Electroconvulsive therapy in children and adolescents. The author of the review, Gordana Milavic, is a child and adolescent psychiatrist at the Maudsley Hospital, London and is enthusiastic about the book. Another review, in an American journal (unfortunately I can’t remember the journal or the author) was rather less enthusiastic. The author wasn’t very keen on the book’s penicillin analogy. There is nothing new about this analogy: Dr Woodlander, who featured in my last post, and had an unusual enthusiasm for using ECT on patients in his general practice, was comparing it to penicillin in 1957. The authors of the review were also sceptical of the position of “lofty certainty” from which the book was written.
The book is edited by psychiatrists Neera Ghaziuddin and Garry Walter, who are based in Michigan, USA, and Sydney, New South Wales, Australia, respectively and was published by Oxford University Press in November 2013. Both the editors have been writing about ECT and children and adolescents for about 20 years. I haven’t read the book so I can’t comment on it, but thought instead that I would look at the extent of use of ECT on young people.
Almost as soon as ECT was introduced it was being used on children, although the vast majority of patients were adults. R.E. Hemphill and W. Grey Walter, from the Bristol City and County Mental Hospital and the Burden Neurological Institute, gave ECT to a three year old. Writing in the Journal of Mental Science (the predecessor of the British Journal of Psychiatry) in 1941 they said:
“The human frame is surprisingly resistant to the profound disturbance which accompany a convulsion. The youngest patient to have an induced convulsion was 3 years old – an epileptic in whom all else had failed to interrupt a series of minor attacks – the oldest a lady of 74 suffering from an agitated depression. Neither of these patients came to any harm.”
The authors were using ECT without anaesthetic and using dose titration, starting with a shock of 130 volts for 0.2 seconds. The largest shock was 150 volts for 0.6 seconds, with a current of about 1 ampere, that is, a shock of much shorter duration than used in modern ECT. Unlike modern authors, the authors were not afraid of using the word shock. For example they wrote: “successive stronger shocks are given until a convulsion is induced”.
In 1942 in France, in occupied Paris, psychiatrists were also using ECT on children. Three psychiatrists writing in a French journal described how a fourteen-year-old boy was given two courses of ECT. He was Jewish and had become depressed when his family was persecuted and his uncle and cousin arrested.
In the United States, psychiatrist Lauretta Bender at Bellevue Hospital in New York in the 1940s gave ECT to over a hundred children, most of them under the age of 12. Some of the children had been subjected to physical and sexual abuse. Writing in 1954 in the Psychiatric Quarterly, E.R. Clardy and E.M. Rumpf of Rockland State Hospital Children’s Unit, who had come across some of Bender’s patients when they were readmitted to hospital and who were not impressed with the results of ECT, described how:
“Following the wide use of electric shock therapy as treatment for mental disorders in adults, investigators and experimenters in this field naturally turned their attention toward children affected with similar disorders. This form of treatment was started on children over a decade ago at Bellevue Hospital… It appears to the writers that one should be fearful of giving electric shock therapy to very young children – those four or five years old – for we have no good understanding of what pathology may take place in the child’s brain or the later effect of shock treatment on the personality that is only in the developmental stage.”
In 2010 an article in Acta Neuropsychiatrica co-authored by Garry Walter, one of the editors of the Oxford University Press book, concluded that “With appropriated checks and safeguards, modern researchers could do worse than follow the example of pioneers like Lauretta Bender.”
During World War II ECT was used by military psychiatrists and some of their patients were older adolescents, for example 18 year olds, who had served in the armed forces.
In Great Britain the first figures on the extent of ECT use on young people came in 1980 when the Royal College of Psychiatrists received funding from the Department of Health to carry out survey of ECT use. The survey looked in detail at 2,594 courses of ECT, which represented about one twelfth of the total for 1980. Thirty-five of those 2,594 courses were given to patients aged under 20. That means that in 1980 about 420 teenagers were given ECT in Great Britain. None of the 35 teenagers in the sample were aged under 16, but ECT has certainly been used on children under 16 both before and after the survey. For example, at least one 12 year-old and two 15-year olds were given ECT in 1996 in the UK, and a 13 year old was amongst patients treated with ECT in Scotland in the mid1980s – mid1990s.
The next reliable statistics including the age of patients came in 1999 when the Department of Health carried out a 3 month survey of ECT in England. The survey found one patient under sixteen and 80 under 25 being given ECT during the 3 month period, representing a fall of about 75 per cent since 1980. In November 2008 it became compulsory to seek approval from the Care Quality Commission in England before giving ECT to anyone aged 18, regardless of whether they were detained or consenting or not (previously it was only compulsory for patients who were not consenting). In their 2009/10 report the Care Quality Commission said that they had given approval for one 17-year-old who was detained to have ECT and had refused approval (a very rare occurrence) for a detained 16-year-old. As for young people who were not detained:
“We received no request to arrange ECT second opinions for informal patients under the age of 18, although we cannot assume that all clinicians caring for such patients will know that certification is required, and therefore cannot say with certainty that no such treatments were given”.
In Scotland, the Mental Welfare Commission’s report for 2012/13 described one person under the age of 18 as being given ECT. Given the diminishing use of ECT on young people in the UK it is not surprising that, except for one of the authors of the chapter on anaesthesia, none of the authors of the Oxford University Press book work in the UK.
Texas is one of the few states in the US that publish statistics on the use of ECT. In 2012/13 three courses of ECT were given to 16-17 year olds and a further 148 to patients aged under 25 (out of a total of 2,243 courses).
In Australia, statistics from Victoria for 2009/10 showed seven teenagers under the age of 18 being given ECT. The youngest patient was 13 years old.
In the Middle East and Asia, the use of ECT on young people is more common. For example a survey of ECT use in Kuwait in 1992 found that 8.2 per cent of patients were aged under 20, while a survey of its use in 29 Asian countries in 2001-2003 found that 6 per cent of patients were aged under 18 years of age. In spite of this none of the contributors to the Oxford University Press book are from Asian countries. Instead they come from North America, Australia, Israel and France.