Electroconvulsive therapy (ECT) may be a useful intervention for children with autism who have psychiatric comorbidities, a new systematic review suggests.

Results of a systematic literature review suggest that ECT has some benefit in patients with autism spectrum disorder (ASD) whose condition is refractory to multiple psychotropic medications.

These results contribute to the growing evidence of the benefits of ECT in young patients with severe ASD, study investigator Raul J. Poulsen, MD, Division of Child and Adolescent Psychiatry, Department of Psychiatry, University of Miami, Florida, told Medscape Medical News.

“It’s very important to be able to balance benefits and risks of any treatment we provide, and this is a step in the direction of gathering that information, to be able to provide the best treatment course for any single individual,” he said.

The results are especially notable given that ASD was significantly treatment resistant in these patients, said Poulsen.

The findings were presented here at the American Psychiatric Association (APA) 2018 annual meeting.

ECT Stigma

Patients with severe ASD typically engage in maladaptive or self-injurious behaviors. Many such patients suffer significant comorbid conditions, including catatonia, attention-deficit/hyperactivity disorder, and intellectual disabilities, said Poulsen.

Some of these patients also have mood disorders. Poulsen noted that ECT has had some success as a treatment for mood disorders, especially treatment-resistant depression.

The investigators researched the published literature in this area to “identify any gaps or any need for further study,” said Poulsen.

Another impetus for conducting the review, he said, was the “significant hesitance of physicians” to suggest ECT for patients “on the severe side of the spectrum” whose conditions are resistant to multiple psychotropic medications.

“Unfortunately,” he added, there is a general stigma about the use of ECT, largely because of negative portrayals of the therapy in the media.

After searching three databases (Cochrane, Embase, and PubMed), the researchers selected 17 articles involving 21 patients. The patients ranged in age from 8 years to 17 years (mean age, 14 years). Most were taking more than three psychotropic medications, said Poulsen.

Treatments for ASD include antipsychotics, antidepressants, stimulants, mood stabilizers, anticonvulsants, and often some form of behavioral therapy, including applied behavior analysis.

In about 76% of cases, treatment involved bitemporal stimulation; in 10%, treatment was unilateral; and in 14%, the type of stimulation was unclear.

Poulsen noted that unilateral stimulation is often used to reduce adverse events. In some studies, the therapy began with bilateral stimulation, and a switch to unilateral stimulation was made if there were side effects.

Patients received 10 to 156 ECT treatments. ECT-induced seizures, measured by EEG, lasted from 26 to 206 seconds.

Most of the studies assessed improvement in self-injurious behaviors, reversal of catatonia, being able to return to school, and being more engaged in day-to-day activities, said Poulsen.

All patients benefited from ECT treatment. The investigators note that there were reports on school attendance for 11 patients, all of whom attended school after ECT.

It is difficult to “tease out” exactly which symptoms ECT improved, because the patients had so many comorbid conditions, said Poulsen. However, he added, ECT releases neurotransmitters, so it helps boost serotonin and dopamine levels in the brain.

“Some of these chemical releases help improve mood,” said Poulsen.

He reported that the treatments were well tolerated by the patients in the studies. Rare side effects included fatigue, hunger, and postemergent agitation.

As with any treatment, the benefits must be weighed against the risks. Risks of ECT include retrograde and anterograde amnesia and headache, Poulsen said.

Not a “Magic Bullet”

Commenting on the study for Medscape Medical News, Neera Ghaziuddin, MD, associate professor of psychiatry, Child and Adolescent Section, University of Michigan, Ann Arbor, said the findings are in keeping with her own experience.

ECT, she said, is useful for children with autism or other developmental disorders who also have a psychiatric condition such as depression.

“It’s not for the autism itself but for this associated condition,” she said.

But children with autism, as well as those with Down syndrome or other intellectual disabilities of unknown cause, are at high risk for psychiatric disorders, said Ghaziuddin.

Ghaziuddin and her colleagues “do quite a bit of ECT in young people” and have found it to be “very helpful.”

“It’s not a magic bullet. It does not treat autism, and that’s an important distinction and thing to remember,” she said.

But it is an “extremely valuable treatment to have available” for young autism patients who have a severe mood disorder or catatonia or for those who engage in extremely severe, life-threatening, self-injurious behaviors or who have psychotic disorders.

Her youngest ECT patient was about 8 years of age, but she has provided consultations on younger patients.

“It’s really the severity of the illness and not age that should be the deciding factor,” she said.

 

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