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Greetings, this is David Rosenberg. In this Smart Take, we delve into a topic that may stir controversy: The use of electroconvulsive therapy (ECT) for adolescents grappling with severe depressive episodes and suicidality. However, it is crucial to acknowledge that even today, there are only 2 FDA-approved antidepressants for treating depression in youth: Escitalopram and fluoxetine. This substantiates an urgent requirement for superior treatment options.
Although these medications are FDA approved, and nonmedication therapies, such as cognitive–behavioral therapy and psychotherapy, can be combined with these treatments, many young individuals with depression remain resistant to the currently available treatment options. Partial responses accompanied by continued functional impairment are common. This problem particularly escalates when depression is associated with suicidality or treatment resistance.
ECT, despite our limited understanding of its workings, remains one of the most effective treatments for depression in adults. Therefore, there is a valid rationale behind its application in adolescents.
The study under discussion was a retrospective comparison between responders and nonresponders. It incorporated all adolescent patients with severe depressive episodes and suicidal tendencies admitted to a psychiatric department who underwent ECT treatment. The cohort comprised nearly 500 adolescents demonstrating severe depressive episodes and suicidal behavior.
According to their measures, treatment proved effective in over 70% of patients but ineffective in about 27%. Notably, 8–12 and 12–16 ECT sessions lessened the risk of ineffectiveness compared with fewer than 4 sessions. Thus, at least 8 ECT sessions seem necessary for satisfactory response in adolescents dealing with severe depressive episodes and suicidality.
Furthermore, the risk of ineffectiveness significantly diminished with age; ECT appeared more effective in older vs younger adolescents. Patients demonstrating comorbidity with obsessive-compulsive disorder (OCD) exhibited significantly increased risk of ECT ineffectiveness. Thus, OCD as a comorbidity emerged as a poor prognostic predictor for response to ECT in adolescents with severe depressive episodes.
Interestingly, escitalopram, when compared with sertraline, was linked to an increased risk of ECT ineffectiveness. This finding is surprising, considering that escitalopram is 1 of only 2 FDA-approved antidepressants for adolescent depression. In contrast, sertraline—despite its use in adolescent depression—lacks FDA approval in this population. Conversely, olanzapine and aripiprazole demonstrated a reduced risk of ECT ineffectiveness when compared with quetiapine, which had a higher risk of ECT ineffectiveness.
Although this study is retrospective, which cannot match the reliability of a prospective study, it does not diminish its significance. Retrospective studies can provide valuable leads but often raise more questions than they answer due to key missing points. These limitations make it challenging to draw definitive conclusions from many findings and associations. Nevertheless, this study provides an essential lead and overall suggests that many patients treated with ECT experienced a favorable response.
Potential predictors have emerged, such as comorbidity with OCD predicting poorer response to ECT; age seems to be a determinant, with older age predicting better response and younger age predicting poorer response. Intriguingly, the antidepressant escitalopram—which is FDA approved for major depression in youth—seems less favorably associated with response to ECT than sertraline, an antidepressant used in adolescent major depressive disorder but yet not having FDA approval.
In conclusion, although there are several significant findings from this study, it underscores the need for further research on the utility of ECT in adolescents suffering from major depression. It also highlights the importance of prospective studies that could build on this retrospective investigation.
Abstract
Electroconvulsive Therapy for Adolescents with Severe Depressive Episode and Suicidality: Retrospective Comparison Between Responders and Non-Responders
Hao Ren, Xinglian Wang, Zheng Zhang, Xiufen Zhong, Qinghua Luo, Haitang Qiu, Yan Huang
Background: For adolescents with major depression who exhibit suicidal tendencies, Electroconvulsive Therapy (ECT) is increasingly adopted in clinical practice. Yet, the precise mechanisms behind its effectiveness remain elusive, and studies on factors that influence treatment outcomes are scarce.
Methods: In this retrospective comparative study, we included all adolescent severe depressive episode patients with suicidal tendencies admitted to the Psychiatry Department of the First Affiliated Hospital of Chongqing Medical University between 2017 and 2021 and received ECT treatment. By collecting data on personal history, medical history, and standard treatment features, we established demographic, disease, medication, and ECT treatment factors variables. Patients were divided into effective and ineffective groups based on the Clinical Global Impressions-Improvement (CGI-I) scale scores, and differences between outcomes were compared. Logistic regression analyses were used to identify factors independently associated with ineffectiveness.
Results: A total of 494 adolescent severe depressive episode patients with suicidal behavior who received ECT were included in this study. According to CGI-I scores, the treatment was effective in 361 patients (73.1%) and ineffective in 133 patients (26.9%). Logistic regression analyses showed that 8 to 12 and 12 to 16 ECT sessions reduced the risk of ineffectiveness compared to fewer than 4 sessions. The risk of ineffectiveness decreased with age and increased with comorbidity with obsessive-compulsive disorder (OCD). Compared to sertraline, escitalopram was associated with a heightened risk of futility, whereas olanzapine and aripiprazole demonstrated a reduced risk when contrasted with quetiapine.
Conclusions: ECT’s ineffectiveness in treating adolescent severe depressive episode with suicidal behavior decreases with age, and comorbidity with OCD significantly increases the risk of treatment failure. Fewer than 8 ECT sessions may hinder achieving satisfactory results.
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Reference
Ren, H., Wang, X., Zhang, Z., Zhong, X., Luo, Q., Qiu, H., & Huang, Y. (2024). Electroconvulsive therapy for adolescents with severe depressive episode and suicidality: Retrospective comparison between responders and non-responders. Child and Adolescent Psychiatry and Mental Health, 18(1).
