Consideration of age

For the most part, ECT is a treatment for adults. For decades, the attitudes of child and adolescent psychiatrists precluded consideration of ECT for all of their patients except the most devastatingly ill. The demonstrated safety of ECT in adults relaxed the prejudice against its use and led to more treatment trials. Once it became clear that the response of adolescents was similar to that of adults, the general attitude changed, and ECT is now an accepted treatment for adolescents with the same illnesses that are successfully treated by ECT in adults.(4 46 and 4Z> Its effective use has also been reported in prepubertal children with catatonia, severe depression, and acute psychosis, relaxing a stubborn rejection of its use in this age group. (4 49)

ECT is widely used in geriatric patients. It is called on when the side-effects of medications become intolerable or when medication trials have failed. Principles of treatment When to consider ECT

Most patients with severe mental illness are first given psychotropic medications and are treated with ECT only after those fail. Since the efficacy of ECT is then demonstrably clear, some physicians have asked whether it may not be wise to spare patients the courses of medications and, instead, apply ECT as the first treatment. Such thinking encouraged the 1990 American Psychiatric Association Task Force on Electroconvulsive Therapy to suggest occasions when ECT might be reasonably applied before medications are tried.(50) It seems appropriate when there is a need for a rapid definitive response, as in suicidal patients who require constant observation and restraint, or in hyperactive patients who may be a risk for themselves or others, or in those whose lives are in jeopardy from systemic illness. Also, of course, it should be considered for patients with delusional depression, manic delirium, catatonia, and neuroleptic malignant syndrome, or those who have had a prior illness that responded well to ECT or had a poor experience with medications.

How many failed trials of medications are reasonable before ECT is applied? For some patients, especially those whose practitioners are not knowledgeable about ECT, medication trials become nearly interminable and ECT is considered only when the disorder becomes worse or when the patient seeks care elsewhere. A more reasonable guideline can be derived from the experimental trials with clozapine, an agent with well-defined life-threatening risks. (51) To put patients at risk and yet obtain the possible benefits of clozapine, the researchers decided that patients who had experienced two unsuccessful courses of neuroleptic medication should be offered clozapine. This seems a reasonable standard for deciding on ECT. Practitioners may want to prescribe two different ourses of medications and apply ECT if both of them fail.

In some circumstances financial considerations may also feature in the decision. If the patient is severely ill and has only a limited ability to pay for extended care, repeated unsuccessful medication trials are unwarranted. All practitioners should balance the cost of medication trials and the effective use of ECT.

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