Electroconvulsive treatment in adolescents with pharmacotherapy-refractory depression

A Multicenter Retrospective Chart Review on the Effectiveness and Tolerability of Electroconvulsive Therapy in Adolescents and Young Adults With Major Depressive Disorder or Bipolar Depression

BACKGROUND

Major depressive disorder and bipolar depression in adolescents and young adults are prevalent and major contributors to the global burden of disease, whereas effective interventions are limited. Available evidence is insufficient to assess effectiveness and tolerability of electroconvulsive therapy in depressed adolescents and young adults.

METHODS

A retrospective chart review was conducted in patients with major depressive disorder or bipolar depression who underwent electroconvulsive therapy from 2001 to 2021 in 12 centers in the Netherlands. Patients were classified as young (15-25 years) and older adults (26-80 years). Primary outcome was effectiveness, expressed as response (≥50% reduction in rating scale score compared with baseline) and remission. Rating scale scores were cross-sectionally assessed at baseline and at the end of the index course. Outcomes of remitters were included in responders. Secondary outcome was occurrence of subjective cognitive impairment and adverse events. Long-term outcomes were not available.

RESULTS

In the young (n = 57) and older adult (n = 41) group, 40.4% and 56.1% (P = 0.153) of patients achieved response and 28.1% and 39.0% (P = 0.281) remission, respectively. Subjective cognitive impairment (80.5% vs 56.3%; P = 0.001) and transient cardiac arrhythmia (14.6% vs 2.8%; P = 0.020) were reported significantly more frequently in the older adult group.

CONCLUSIONS

Despite significantly more comorbidity of personality disorders, autism spectrum disorders, and anxiety disorders, effectiveness in the young was similar to the older adults. Tolerability was even superior in the young, despite significantly more bilateral treatment. Electroconvulsive therapy could be considered a viable treatment option in depressed adolescents and young adults.

Suicidal Ideation and Electroconvulsive Therapy: Outcomes in Adolescents With Major Depressive Disorder

OBJECTIVE

Few studies on electroconvulsive therapy (ECT) investigate efficacy and safety on depressive adolescents with strong suicidal ideation. Our study examined adolescents (aged 13-18 years) with major depressive disorder to explore ECT effectiveness in improving suicidal ideation and depressive symptoms, as well as its impact on cognitive function.

METHODS

This nonrandomized controlled trial enrolled 183 adolescent patients suffering from major depressive disorder. The ECT group (n = 81) was treated with antidepressants and 8 rounds of ECT for 2 weeks. The control group comprised 79 patients treated with antidepressants only. Depressive symptoms, suicidal ideation, and cognitive functions were assessed at baseline (pre-ECT) and at 2 and 6 weeks post-ECT.

RESULTS

The ECT group showed significant improvements over control in suicidal ideation from the end of treatment to 6 weeks after ( P < 0.001). Depressive symptoms also improved ( P < 0.001). Patients treated with ECT demonstrated poorer performance in delayed memory, attention, and language, but these impairments were transient. Thus, ECT was generally safe in adolescent patients with major depressive disorder.

CONCLUSIONS

Our findings verified ECT as effective and safe for improving suicidal ideation and depressive symptoms of adolescent patients with major depressive disorder. In addition, partially impaired cognitive function recovered gradually after ECT.

Systematic review: Electroconvulsive therapy for treatment-resistant mood disorders in children and adolescents

Electroconvulsive therapy (ECT) is a well-established treatment for adults with mood disorders. However, its use in child and adolescent populations is less common. At the same time, approximately 60% of child and adolescent patients do not respond satisfactorily to first-line treatments for mood disorders. Given the need for effective treatments for severe mood disorders in adolescents and the low use rate of ECT, this systematic review examines the existing literature on the effectiveness and adverse effect profile of ECT when used for treatment-resistant mood disorders in children and adolescents. Searches were conducted in Medline, Embase, and PsycInfo using search terms related to (1) children and adolescents, (2) mood disorders, and (3) ECT. Searches identified 1715 unique articles. The full text of 71 selected articles were reviewed, leading to 41 studies included in the study. A standardized data extraction tool was used to collect key information from each study (i.e. author and publication year, objectives, participants and setting, design, measures, clinical outcomes, and side effects). As most of the studies found were case series, the Joanna Briggs Institute Case Series Critical Appraisal tool was used to assess quality. Studies were summarized qualitatively by comparing findings across key study parameters. Our review identified 41 studies for inclusion. Twenty were case series, two were case-control studies, and nineteen were case reports. Overall treatment response rates ranged from 51 to 92%, with patients receiving an average of 12 treatments. Among studies with n > 30, response rates were largely 70-82% for depression and 87-90% for mania. Seven studies used the Mini-Mental State Exam and found no evidence of significant post-treatment cognitive impairment. The majority of side effects were minor and transient. Tardive seizure was reported in 4 (0.6%) patients. ECT was discontinued early due to side effects in 11 (1.5%) cases. No fatalities were reported. Our data suggest that ECT is safe and effective for the treatment of mood disorders in child and adolescent populations, and should be considered in severe and treatment-refractory cases. Controlled studies with objective measures and long-term follow-up are needed to advance the evidence base.

Electroconvulsive Therapy in Children and Adolescents in Germany-A Case Series From 3 University Hospitals

OBJECTIVE

Electroconvulsive therapy (ECT) is a well-established, safe, and efficacious treatment for severe psychiatric disorders. In children and adolescents, it is used much less frequently than in adults, likely because of a lack of knowledge.

METHODS

We retrospectively analyzed all patients aged 12 to 17 years who completed a course of ECT at 3 psychiatric university hospitals in Germany between 2010 and 2020. Clinical Global Impression Severity (CGI-S) scores were assessed based on electronic medical records. Changes in CGI-S scores were assessed using a paired samples t test. Predictors for response and remission were assessed using binomial logistic regression.

RESULTS

We included 32 patients. The CGI-S scores improved significantly from before to after ECT treatment (6.9 vs 3.9, t = 10.0, P < 0.01). A total of 40.6% of patients responded (CGI ≤ 3) and 21.9% remitted (CGI ≤ 2). The number of ineffective medication trials in the 6 months before ECT treatment was significantly associated with response (odds ratio, 0.54; P = 0.028) and remission (odds ratio, 0.31; P = 0.048). Five patients reported subjective cognitive adverse effects, 2 patients exhibited a prolonged seizure, 1 patient reported headaches, and 1 patient experienced a mild allergic reaction after anesthesia with etomidate. A total of 65.6% of patients experienced no adverse effects at all.

CONCLUSIONS

This retrospective analysis found ECT to be effective and safe in children and adolescents irrespective of their main diagnosis. The reported data point to the importance of an early use of ECT for severe psychiatric diseases in child and adolescent psychiatry.

A comparison of the safety, feasibility, and tolerability of ECT and ketamine for treatment-resistant depression

INTRODUCTION

Treatment-resistant depression (TRD) is a problematic and prevalent public health and societal concern. Although electroconvulsive therapy (ECT) is the gold standard TRD intervention, the treatment evokes apprehension due to public perceptions, feasibility, and tolerability. Despite significant medical advancements, few medications have been approved by the U.S. Food and Drug Administration for TRD. In 2019, intranasal esketamine, the S-isomer of racemic ketamine, was approved for TRD, garnering significant excitement about the potential for the drug to act as an alternative treatment to ECT.

AREAS COVERED

The goal of this narrative review is to compare the safety, efficacy, and tolerability of ketamine and ECT; clarify whether ketamine is a reasonable alternative to ECT; and to facilitate improved treatment assignment for TRD. Empirical quantitative and qualitative studies and national and international guidelines these treatments are reviewed.

EXPERT OPINION

: The field awaits the results of two ongoing large comparative effectiveness trials of ECT and IV ketamine for TRD, which should help guide clinicians and patients as to the relative risk and benefit of these interventions. Over the next five years we anticipate further innovations in neuromodulation and in drug development which broadly aim to develop more tolerable versions of ECT and ketamine, respectively.

A systematic review of therapeutic ketamine use in children and adolescents with treatment-resistant mood disorders

Suicide is the second leading cause of death in the United States among individuals aged 10-24, and severe youth depression is often refractory to the current standards of care. Many studies have demonstrated the efficacy of ketamine in reducing depressive symptoms in adults with treatment-resistant mood disorders, though few studies utilizing ketamine in youth populations exist. This systematic review examines the current state of evidence for ketamine use in children with treatment-resistant mood disorders. We conducted a search utilizing two electronic databases for English-language studies investigating the therapeutic effects and side effect profile of ketamine in youth ≤ 19 years of age with a diagnosis of a treatment-resistant mood disorder. Analysis included subjects with treatment-resistant depression with and without psychotic features and with bipolar disorder. Primary outcome measures included the following scales: Montgomery-Asberg Depression Rating Scale, Children's Depression Rating Scale, Children's Depression Rating Scale Revised, Child Bipolar Questionnaire, Overt Aggression Scale, Yale-Brown Obsessive-Compulsive Scale, and Scale for Suicidal Ideation. Four published studies were identified that investigated therapeutic ketamine use in youth for the primary purpose of treating a treatment-resistant psychiatric disorder. Three additional studies that did not meet eligibility criteria were identified and discussed. Ketamine was shown in youth to generally improve depressive symptoms, decrease acute suicidality, and reduce mood lability, though a number of subjects remained resistant to its treatment. These findings substantiate the need for further longitudinal studies investigating ketamine's long-term safety, its efficacy, and abuse potential in the youth.

Electroconvulsive Therapy in Children and Adolescents: A Systematic Review of Current Literature and Guidelines

ABSTRACT

There is a lack of studies regarding the efficacy of electroconvulsive therapy (ECT) in children and adolescents. In this study, we aimed to assess benefits and harms of ECT in children and adolescents with major psychiatric diseases. We conducted a systematic search in PubMed, EMBASE, and PsycINFO for peer-reviewed articles written in English regarding the use of ECT as treatment for major psychiatric diseases in children and adolescents. This study consists of 192 articles, mostly case studies (n = 50), reviews and overview articles (n = 52), and retrospective studies (n = 30). We present an overview of evidence for ECT in children and adolescents with mood disorders, catatonia, schizophrenia, intellectual disability, self-injurious behavior, and other indications. This article is also a summary of international guidelines regarding the use of ECT in children and adolescents. We evaluated the overall quality of evidence by using Grading of Recommendations, Assessment, Development and Evaluations and found the overall level of evidence to be of low quality. There are no absolute contra indications for ECT in children and adolescents. Fears regarding cognitive dysfunction have not been reproduced in studies. Electroconvulsive therapy should be considered in severe, treatment-resistant mood disorders, catatonia, and schizophrenia, especially in older adolescents. High-quality studies are warranted to assess the efficacy of ECT, especially in these potentially life-threatening diseases.

[Use of electroconvulsive therapy in adolescents - A retrospective survey on 12- to 17-year-old patients at three university hospitals in Germany]

Use of electroconvulsive therapy in adolescents - A retrospective survey on 12- to 17-year-old patients at three university hospitals in Germany Abstract. Abstract. Background: Electroconvulsive therapy (ECT) is a highly effective and well-researched therapy in adult psychiatry and has been successfully used especially as a treatment for severe depressive, catatonic, and psychotic disorders. Although severe disease progressions also occur in child and adolescent psychiatry, ECT is used much less frequently there. This may be because hardly any data have been collected on the use, effectiveness, and tolerability of ECT in child and adolescent psychiatric patients. This article outlines the application, effectiveness, and tolerability of ECT when applied to young adolescents in Germany. Methods: A retrospective survey on ECT in 29 patients under 18 years of age was conducted at three German university centers. All documented cases were recorded and evaluated for effectiveness and tolerability. In addition, a comprehensive PubMed-based database search was carried out. Results and conclusions: Internationally, there are no meta-analyses or randomized controlled studies and hardly any published cases on electroconvulsive therapy in German child and adolescent psychiatry. Our data on ECT show high efficacy in previously treatment-resistant and severely ill patients. Side effects occurred rarely. There was no evidence of differences between adults and adolescents in indication (depression, catatonia, schizophrenia), effectiveness, tolerability, and negative predictors of response to ECT. The results also suggest that the use of ECT in adolescents should be considered earlier in the treatment course.

The Incidence of Post-Electroconvulsive Therapy Headache: A Systematic Review

Headache is a common side effect of electroconvulsive therapy (ECT), but reports on its incidence vary widely. A broad array of treatment regimens have been proposed in the literature. The pathophysiology of post-ECT headache is unclear but a vascular origin has been suggested. A systematic literature search was executed in PubMed and Embase to identify relevant articles. Articles were screened on title, abstract, and full text according to predefined inclusion and exclusion criteria. Study characteristics and results concerning the incidence of post-ECT headache were extracted, and a weighted mean incidence was calculated. Forty-seven relevant articles were found, of which 36 reported on the incidence of post-ECT headache in patients and 9 on the incidence in sessions. The incidence of post-ECT headache varied greatly in the literature. The weighted mean incidence in patients was 32.8%, as 786 of a total population of 2399 patients experienced headache. The weighted mean incidence in sessions was between 9.4% (246 of 2604 sessions) and 12.1% (236/1958 sessions). The variation in incidences of post-ECT headache found might be due to different methods of measuring headache, different study designs, and different drugs used for anesthesia. The mean-weighted incidence of post-ECT headache in patients was 32.8% and in sessions between 9.4% and 12.1%.

Electroconvulsive Therapy in Children and Adolescents: Clinical Indications and Special Considerations

Electroconvulsive therapy (ECT) is a well-tolerated, well-established, and efficacious treatment in adults, particularly in the setting of severe mood and psychotic disorders. In children and adolescents, however, ECT is infrequently administered and likely underutilized. Results from older studies evaluating the utility of ECT in children and adolescents were mixed, but recent studies have supported ECT treatment success in these patients, with particularly high response rates for treating depression. In this Perspectives, we discuss the current clinical indications for ECT in managing mood and psychotic disorders in children and adolescents. We then review the pretreatment evaluation and management of patients receiving ECT and examine the efficacy of ECT for those indications. We also address issues unique to children and adolescents, versus adults, that need to be considered when determining whether treatment with ECT is appropriate for a patient in this age group. Included in this context are the distinct side-effect profile in children and adolescents, ethical issues regarding informed consent, incorporating the child into the decision-making process when developmentally appropriate, and the need to take into account differing state jurisdictional processes.

Electroconvulsive Therapy for the Treatment of Severe Mood Disorders During Adolescence: A Retrospective Chart Review

Objective: Electroconvulsive therapy (ECT) is a well-recognized treatment of refractory mood disorders in adults. However, relatively little is known about its use for similar conditions in adolescents. Based on a chart review, we describe its use and outcome in a sample of adolescents with severe, refractory mood disorders (unipolar or bipolar disorder) hospitalized in an academic medical center. Methods: The sample was drawn from referrals to an adolescent psychiatry service. After obtaining approval from the ethics board, medical records of 54 adolescents with refractory mood disorder were examined. Participants (males 24, females 30; mean age 15.8 ± 1.5 years) had received their first course of ECT before the age of 18 years during the period 1996-2010. Response to treatment was examined after the initial treatment and during a 1-year follow-up. Results: Following the index course of ECT (mean number of treatments = 13.7 ± 6.3), a 52.8% response rate (defined as a Clinical Global Impressions [CGI] score ≤2) was noted, while 15.1% achieved remission (CGI = 1). The response rate was 82.4% after a 1-year follow-up with a remission rate of 23.5%. The Children's Depression Rating scores declined significantly from pre-ECT to the end of the index course (70.7 ± 16.4 to 52.5 ± 18; p ≤ 0.00). A reduction in suicidal ideation and self-injurious behaviors along with increased school attendance was noted. Cognition, monitored by the Mini-Mental State Examination, did not decline significantly. Minor side effects were limited to the day of the treatment. Prolonged seizures (>2 minutes) were common during ECT (74% of subjects experienced one or more). The only side effect noted at the 1-year follow-up was self-reported memory loss involving events during and around the index treatment course. Conclusions: In this severely impaired sample of adolescents, ECT was found to decrease suicidal behavior, reduce depressive symptoms, and improve overall functioning, as indexed by school attendance at follow-up after 1 year. Prospective studies using large samples are needed to determine its effectiveness and safety in refractory mood disorders in adolescents.

Efficacy and Safety of Electroconvulsive Therapy in Adolescents: A Retrospective Chart Review Study From Turkey

OBJECTIVE

The aim of this study was to report the efficacy and safety of electroconvulsive therapy (ECT) in manic, depressed, psychotic, and catatonic adolescent patients.

METHODS

Medical records of 78 adolescents who had received ECT in Department of Psychiatry, Gaziantep University Medical Faculty, during 2011 to 2017 were reviewed. Sixty-two subjects in this sample were identified to have complete records and met the study inclusion criteria.

RESULTS

The mean ± SD age of subjects was 17.11 ± 1.04 years and female sex was 53.2% (n = 33). Primary the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision or the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition diagnoses were bipolar mood disorders (n = 33, 53.2%), major depressive disorder (n = 16, 25.8%), schizophrenia (n = 8, 12.9%), and schizoaffective disorders (n = 5, 8.1%). Electroconvulsive therapy was significantly effective in treating manic, depressive, psychotic, and catatonia symptoms as evidenced by significant differences in pretreatment and posttreatment scores in outcome measures including Hamilton Depression Rating Scale, Young Mania Rating Scale, Positive and Negative Syndrome Scale, and Clinical Global Impression-Severity Scale (P < 0.001). Presence of comorbidity adversely affected treatment response (P = 0.001). However, ECT was also effective in those with comorbid diagnoses (P < 0.001). Depressive symptoms in patients with bipolar depression responded better than those with unipolar depression (P = 0.012). Electroconvulsive therapy was generally safe with subjective memory complaints (85%), headache (69%), and prolonged seizure (8%) as the reported adverse effects possibly related to ECT. Four subjects (6%) developed a manic switch during ECT.

CONCLUSIONS

Electroconvulsive therapy is an effective and a safe treatment option in adolescent patients with severe and resistant psychopathology. Although comorbidity may decrease treatment response, ECT seems to be effective even in the presence of multiple psychiatric diagnoses.

Knowledge, attitudes, and experience of child and adolescent psychiatrists in Turkey concerning pediatric electroconvulsive therapy

OBJECTIVE

Electroconvulsive therapy (ECT) is a treatment modality in children that can be life-saving but is rarely preferred. In this study, we aimed to evaluate the knowledge, experience, and attitudes of child and adolescent psychiatrists (CAPs) in Turkey about pediatric ECT and to draw attention to possible gaps and needs regarding this treatment in the child and adolescent psychiatric policies of Turkey.

METHOD

An electronic survey was prepared and shared with child and adolescent psychiatric residents and specialists. The participants were asked about their residency training, clinical experience, and opinion about ECT. The obtained data were entered in SPSS Statistics 23.0. Descriptive analyses and chi-squared tests were applied.

RESULTS

One hundred and ninety-one CAPs filled in the questionnaire, 28.8% of whom assessed their knowledge level as "I have no knowledge." Only 34% of them stated that their patients, most of whom had mood disorders, schizophrenia, and catatonia, had received ECT before. Four of these patients were under 12 years old. Sixty-six percent of the participants suggested that ECT was safe in adolescents, whereas only 5.8% held this view for prepubertal children. The most common reason for physicians not to apply ECT was "lack of means to apply ECT," and 92.7% stated that opportunities should be provided for pediatric ECT treatment by the hospital administration.

CONCLUSION

This is the first data to present the knowledge and attitudes of CAPs in Turkey about ECT. The results suggest that physicians need to have more knowledge about ECT.

A Follow-up Study of Electroconvulsive Therapy in Children and Adolescents

OBJECTIVES

Electroconvulsive therapy (ECT) is an effective and a safe treatment for several severe psychiatric disorders across the age span. However, its use remains controversial and highly stigmatized especially among patients under 18 years. In this study, we examined current symptoms, attitudes, perception, and functioning of patients treated with ECT when they were less than 18 years old.

METHODS

Participants had received ECT before age 18, between 1989 and 2015, at a tertiary medical center. Institutional review board-approval was obtained, and study documents (cover letter, consent, self-ratings scales for depression, anxiety, global functioning, and suicidality) were mailed.

RESULTS

Based on self-rated depression, 59.1% (13/22) participants indicated mild or no depression; 65% (13/20) reported mild or no anxiety; the majority, 84.3% (16/19) perceived ECT as having improved their overall illness; and 27.3% (6/22) among the respondents reported no clinical impairment on a global functioning scale, whereas 72.7% (16/22) reported significant or severe impairment. Despite reports of ongoing impaired global functioning among some participants, adequate academic performance (83.3%, 5/6) and mild or no suicidality (78.3%, 18/23) were endorsed by the majority reported.

CONCLUSIONS

The majority of participants who had received ECT before age 18 years reported mild or absence of depression and anxiety on self-rated follow-up measures after treatment with ECT. Most notably, the majority reported absence of suicidality and adequate academic performance. A number of respondents, however, continued to endorse global impairment, which may be a reflection of their baseline severe illness, which had warranted treatment with ECT.

A review of repetitive transcranial magnetic stimulation for adolescents with treatment-resistant depression

This review examines the efficacy and safety of repetitive transcranial magnetic stimulation (rTMS) as a treatment for treatment-resistant depression in adolescents. A systematic review of six databases was conducted. Ten multi-subject trials, all uncontrolled, and five case reports met inclusion criteria. Twelve studies focused on treatment efficacy, whereas three studies focused exclusively on adverse events. All efficacy studies focused on adolescents only; 10 of these studies indicated that rTMS may demonstrate some benefit. Improvement within 2-8 weeks was reported in most studies, with a few studies indicating potential long-term benefits. A variety of adverse events occurred including scalp pain, which was the most common, as well as seizures. Controlled studies of rTMS are warranted to further examine whether this treatment is a potential option for adolescents with treatment-resistant depression.

Neural Rhythmicity, Feature Binding, and Serotonin: A Hypothesis

Natural selection favors animals that make successful predictive theories about the world. The first step in the formation of these theories is the construction of complex, multifea ture percepts. This process requires resolution of the binding problem, possibly via rhyth mic cortical oscillations, as suggested by von der Malsburg, Singer, Koch & Crick, and others. If the binding process were made rewarding, animals might enjoy theory-making and spontaneously become "smarter." I argue that the serotonergic raphe may have been used by evolution to link cortical binding with limbic reward centers and so serve as a neural substrate for the enjoyment of successful theory-making. I present evidence, from the study of such disorders as obsessive-compulsive disorder and autism and such drugs as d-lysergic acid diethylamide (LSD) and 3,4-methylenedioxymethamphetamine (MDMA), suggesting that rhythmicity, reward, and pattern recognition are causally linked. I also propose that the genus Homo has tied powerful symbol manipulation hardware ("language") to the binding/theory-making circuits, allowing the construction, rehearsal, and communication of sophisticated models of the world. I suggest that many interesting phenomena, such as music-induced euphoria, déjà vu, and the so-called "temporal lobe personality" can be explained by the interactions between these systems. NEURO SCIENTIST 5:79-85, 1999

Patients' Opinions About Electroconvulsive Therapy: What Do Adolescents with Schizophrenia Spectrum Disorders Think?

OBJECTIVE

The purpose of this study was to assess, in patients with schizophrenia spectrum disorders (SSD) who received electroconvulsive therapy (ECT) prior to the age of 18, their experience, knowledge, and attitudes toward ECT, and to compare the findings with those obtained in adolescents treated only with antipsychotics.

METHODS

Patients diagnosed with SSD (n = 19) and treated with ECT before the age of 18 years (ECT group; n = 19) were compared with a randomly selected group of patients with SSD treated only with antipsychotics (non-ECT group, n = 21). A self-administered questionnaire was used to assess their experience, knowledge, and attitudes.

RESULTS

Most adolescents in the ECT group thought that the intervention had been helpful (78.9%) and believed that their illness had been worse than ECT or medication (68.4%). Similarly, almost three quarters of these patients did not believe the treatment to be cruel (73.7%) or outdated (73.7%), or that it should be illegal (68.4%). Patients in the non-ECT group often chose "don't know" as their response to the survey questions, and significant differences between the groups were observed. Most patients in both the ECT group (84.2%) and the non-ECT group (80%) said that they would accept the treatment in the future if necessary, there being no differences between the groups in this respect (p = 0.2).

CONCLUSIONS

Most adolescents in the ECT group had positive views about ECT. By contrast, most adolescents in the non-ECT group either did not know or did not have a clear opinion regarding ECT treatment, although they did not have negative views about it.

The treatment of depressive disorders in children and adolescents

BACKGROUND

Depressive disorders are among the more common mental illnesses around the world. About 3% of prepubertal children and 6% of postpubertal children and adolescents are affected. Many physicians are unsure about which treatment approaches are effective and how the treatment should be planned.

METHOD

A systematic literature search was carried out in electronic databases and study registries and as a manual search. More than 450 studies (mostly randomized controlled trials [RCTs]) were identified and summarized in five evidence tables. The ensuing recommendations were agreed upon in a consensus conference in which 23 organizations were represented.

RESULTS

The recommended treatment of first choice for children from age 8 onward and for adolescents is either cognitive behavioral therapy (CBT) (Cohen's d [effect strength]: 0.5-2) or interpersonal psychotherapy (Cohen's d: 0.5-0.6). Fluoxetine is recommended for drug treatment (Cohen's d: 0.3-5.6), either alone or in combination with CBT. The analysis revealed a lower level of evidence for psychodynamic or systemic psychotherapy or for drug treatment with escitalopram, citalopram, or sertraline. For mild or moderate depression, psychotherapy is recommended; for severe depression, combination therapy. Particularly for children, there is a lack of adequately informative comparative studies on these treatment approaches as well as on other, complementary interventions (e.g., art therapy, sleep deprivation, youth welfare services).

CONCLUSION

There is adequate evidence to support some recommendations for the treatment of depressive disorders in adolescents, but evidence for children is lacking. There is a pressing need for intervention research in this area for both children and adolescents.

Two-year follow-up of cognitive functions in schizophrenia spectrum disorders of adolescent patients treated with electroconvulsive therapy

OBJECTIVE

The aim of the current study was to investigate the long-term cognitive effects of electroconvulsive therapy (ECT) in a sample of adolescent patients in whom schizophrenia spectrum disorders were diagnosed.

METHODS

The sample was composed of nine adolescent subjects in whom schizophrenia or schizoaffective disorder was diagnosed according to DSM-IV-TR criteria on whom ECT was conducted (ECT group) and nine adolescent subjects matched by age, socioeconomic status, and diagnostic and Positive and Negative Syndrome Scale (PANSS) total score at baseline on whom ECT was not conducted (NECT group). Clinical and neuropsychological assessments were carried out at baseline before ECT treatment and at 2-year follow-up.

RESULTS

Significant differences were found between groups in the number of unsuccessful medication trials. No statistically significant differences were found between the ECT group and the NECT group in either severity as assessed by the PANSS, or in any cognitive variables at baseline. At follow-up, both groups showed significant improvement in clinical variables (subscales of positive, general, and total scores of PANSS and Clinical Global Impressions-Improvement). In the cognitive assessment at follow-up, significant improvement was found in both groups in the semantic category of verbal fluency task and digits forward. However, no significant differences were found between groups in any clinical or cognitive variable at follow-up. Repeated measures analysis found no significant interaction of time×group in any clinical or neuropsychological measures.

CONCLUSIONS

The current study showed no significant differences in change over time in clinical or neuropsychological variables between the ECT group and the NECT group at 2-year follow-up. Thus, ECT did not show any negative influence on long-term neuropsychological variables in our sample.

Use of continuation or maintenance electroconvulsive therapy in adolescents with severe treatment-resistant depression

Retrospective data are presented for 6 adolescents ranging in age from 14 to 17 years, who were diagnosed with severe treatment-resistant major depression (TRD). Subjects were treated with one or more index courses of electroconvulsive therapy (ECT) followed by continuation ECT (C-ECT, up to 6 months of ECT) or maintenance ECT (M-ECT; ECT beyond 6 months) when necessary. Electroconvulsive therapy was continued until remission or until minimal residual symptoms were evident. Pharmacotherapy and psychotherapy were reintroduced during C-ECT or M-ECT. Premorbid functioning was achieved by 5 of 6 cases. Cognitive deficits were not evident. In fact, comparison of pre-ECT and post-ECT neuropsychological functioning revealed a trend toward improved auditory and verbal memory on most of the results. We concluded that C-ECT and M-ECT are useful and safe treatment strategies for selected adolescents with severe treatment-resistant depression, and symptom remission may be achieved without experiencing cognitive impairment.

Electroconvulsive therapy in adolescents with the catatonia syndrome: efficacy and ethics

OBJECTIVES

In child and adolescent psychiatry, catatonia is infrequent, but it is one of the most severe syndromes, characterized by the coexistence of psychic and motor symptoms. In this report, we explore the therapeutic experience with electroconvulsive therapy (ECT) in adolescents with catatonia.

METHODS

We review the literature (1985-2009) to clarify issues related to the use of ECT in child and adolescent patients with catatonia.

RESULTS

Electroconvulsive therapy is used as second-line management after high-dose benzodiazepine trials. Electroconvulsive therapy is an effective, safe, and useful procedure in the treatment of catatonic youngsters as reported in 59 patients. Ethical issues regarding the use of ECT are analyzed and their implications briefly discussed in the light of general medical ethics.

CONCLUSIONS

Electroconvulsive therapy is a safe and effective treatment for catatonia in children and adolescents.

Clinical experience using electroconvulsive therapy in adolescents with schizophrenia spectrum disorders

OBJECTIVES

The aim of this study was to evaluate the effectiveness and safety of electroconvulsive therapy (ECT) in adolescent patients diagnosed with schizophrenia spectrum disorders (SSD).

METHODS

All patients diagnosed with SSD who received ECT in the Child and Adolescent Psychiatry and Psychology Department in a general hospital in Barcelona, Spain, from January, 2003, to December, 2007, were identified retrospectively. As part of the usual evaluation protocol, Positive and Negative Syndrome Scale (PANSS) and Clinical Global Impression (CGI) scales were administered before ECT, after the acute ECT phase (CGI), and at 6 months from baseline. Data related to characteristics of these patients such as demographics, pharmacological treatment, ECT parameters, and side effects were registered.

RESULTS

Thirteen cases, ages 13-17 (mean age, 16.6 +/- 1.2 years), were included. Compared to pre-ECT scores, mean PANSS decreased significantly at 6-month assessment (t = 3.58, p = 0.004). Clinical response (20% or greater reduction in PANSS total scores at the 6-month end point) was achieved in 54% of patients. A significant improvement of mean CGI score was observed after the acute ECT phase (t = 11.88, p < 0.001) and at 6-month assessment (t = 12.48, p < 0.001). There were no severe incidents related to any session during the acute ECT phase, although 1 patient experienced a tardive seizure during the continuation ECT.

CONCLUSIONS

Our clinical experience supports the assertion that ECT is a safe and effective treatment for SSD in adolescent patients.

[Severe catatonic schizophrenia in a 17-year-old adolescent]

OBJECTIVES

Catatonic symptoms in children and adolescents have not been well investigated and there are hardly any evaluated recommendations for treatment. The present report deals with the course of disease and the therapy of a severe case of catatonic schizophrenia.

METHODS

Reported is the case of a 17-year-old-girl suffering from severe, life-threatening catatonic schizophrenia.

RESULTS

Following unsuccessful pre-treatment, medication with clozapine markedly improved the pathology.

CONCLUSIONS

Further investigations and case reports about the course of disease and the therapy of the uncommon clinical picture of sever catatonic schizophrenia in children and adolescents are necessary.

Moderate clinical improvement with maintenance ECT in a 17-year-old boy with intractable catatonic schizophrenia

The use of electro-convulsive therapy (ECT) in adolescents is controversial, and few studies have been conducted to assess its efficacy and safety in this population. We report the case of a 19-year-old boy who received two series of ECT, one at 15 and another at 16, for intractable catatonic schizophrenia. Since the age of 17, he has required treatment combining clozapine and maintenance ECT. The course showed a sustained moderate improvement. The treatment permitted the patient to regain some autonomy with moderate adverse effects. ECT remains an uncommon treatment in adolescents, and the current case supports the view that it should not be banned in young people.

Tardive seizure: a case report

Electroconvulsive therapy remains the best option for treatment-resistant depressive episodes. A rare, but potentially dangerous, complication is tardive seizures, which occur after the patient has already stopped convulsing from the electroconvulsive therapy and has recovered full consciousness. We have decided to report this case, which many psychiatrists and psychiatry residents may not be familiar with, to heighten the awareness of the condition because it has ramifications in terms of safe management of the patients concerned.

Electroconvulsive therapy and transcranial magnetic stimulation: can they be considered valid modalities in the treatment of pediatric mood disorders?

Depression in children and adolescents is a severe and debilitating disorder and can be life-endangering. Even when it is not life-endangering, however, it has a grave impact on the quality of life of youngsters and their families, and interferes with normal growth and development. In recent years, the field of child psychiatry has become more aware of the limited applicability of data from the adult literature to children and adolescents and the limited resources that child psychiatrists have in treating depression. This awareness substantiates the need to define the place of electroconvulsive therapy and transcranial magnetic stimulation in the treatment of pediatric depression.

ECT and The Youth: Catatonia in Context

Electroconvulsive therapy (ECT) has been in psychiatric practice for well over half a century, but it continues to incite controversy. However, it is regarded amongst psychiatrists as a safe and effective treatment and at times even a lifesaver. It offers a fairly swift but a time-limited response, opening up opportunities for initiation of more longer lasting treatments. The use of ECT in the youth is limited, and as such good studies are few and far between. The recent Practice Parameters by the American Academy of Child and Adolescent Psychiatry, specifically addressing ECT in adolescents, is indeed a welcome addition. Electrocovulsive therapy is as effective in the youth as it is in the adults, and the indications and contraindication are the same. The administration of ECT follows the same general principles in all age groups. One particular indication is of the use in catatonia, a motor syndrome that could occur with affective disorders, schizophrenia or medical conditions, in which it is considered to be extremely effective. The association between catatonia and autism and spectrum disorders has been noted, and in this situation, ECT is considered by some to be effective. Ethical considerations and that of capacity and informed consent are of paramount importance as are the human rights. Working in partnership with the parents/carers all the way is a must. The lack of information leaflets on ECT especially designed for young patients and their parents has to be rectified soon. Registers based on geographical health regions for those below the age of 18 will assist tremendously in epidemiological studies as well as pave the way toward more evidence-based studies that are essential.

Practice parameter for use of electroconvulsive therapy with adolescents

Electroconvulsive therapy (ECT) may be an effective treatment for adolescents with severe mood disorders and other Axis I psychiatric disorders when more conservative treatments have been unsuccessful. ECT may be considered when there is a lack of response to two or more trials of pharmacotherapy or when the severity of symptoms precludes waiting for a response to pharmacological treatment. The literature on ECT in adolescents, including studies and case reports, was reviewed and then integrated into clinically relevant guidelines for practitioners. Mood disorders have a high rate of response to ECT (75%-100%), whereas psychotic disorders have a lower response rate (50%-60%). Consent of the adolescent's legal guardian is mandatory, and the patient's consent or assent should be obtained. State legal guidelines and institutional guidelines must be followed. ECT techniques associated with the fewest adverse effects and greatest efficacy should be used. The presence of comorbid psychiatric disorder is not a contraindication. Systematic pretreatment and posttreatment evaluation, including symptom and cognitive assessment, is recommended.

Leitlinien zur Diagnostik und Psychotherapie von depressiven Störungen im Kindes- und Jugendalter: Ein evidenzbasierter Diskussionsvorschlag

Zusammenfassung. Ein Entwurf evidenzbasierter Leitlinien zur Diagnostik und Psychotherapie von depressiven Störungen im Kindes- und Jugendalter wird vorgestellt. Für die Diagnosestellung depressiver Störungen im Kindes- und Jugendalter müssen die gleichen diagnostischen Kriterien nach ICD-10 erfüllt sein wie für Erwachsene. Allerdings kann das klinische Bild einer Depression in verschiedenen Altersgruppen deutlich variieren. Depressive Störungen sind vor allem im Jugendalter häufig, chronische Verläufe und Rückfälle treten auf und sie gehen oft mit komorbiden Störungen wie Angststörungen, Störungen des Sozialverhaltens und Störungen durch Substanzgebrauch einher. Wirksame Interventionsansätze zur Prävention depressiver Störungen und zur Akutbehandlung bei leichten und mittelschweren depressiven Störungen stehen zur Verfügung. Die psychotherapeutischen Interventionen der Wahl stellen derzeit kognitiv-verhaltenstherapeutische Ansätze (KVT) und die interpersonale Therapie (IPT) dar. Die Antidepressiva der Wahl sind derzeit selektive Serotoninwiederaufnahmehemmer (SSRI). Weitere Studien, vor allem hinsichtlich Rückfallprophylaxe und der Evaluation der Wirksamkeit einer Kombinationsbehandlung von Psychotherapie mit antidepressiver Medikation stehen noch aus.

Somatic treatment for depressive illnesses in children and adolescents

Numerous somatic interventions have been studied as potential treatments of depressive disorders in children and adolescents. These include antidepressant medications, light therapy, electro-convulsive therapy, and alternative therapies. The available evidence suggests that several somatic interventions hold promise as potentially safe and effective treatments for depressed youths; however, there is still much to be learned about these interventions. This article reviews what is known and what needs to be learned about the somatic treatment of pediatric depression.

Tratamiento electroconvulsivo en niños y adolescentes

It is well-known that electroconvulsive therapy (ECT) is a safe and effective treatment for some mental disorders in adults. However, its use in children and adolescents is still the cause of some fears which may not be justified. The aim of this article is to clarify and to present the state of this question by reviewing the literature about ECT in children and adolescents, with emphasis on efficacy, indications, adverse effects and limitations. Results from studies in this population group show similar safety and efficacy data as those observed in adults. There exists a misinformation about the ECT technique among child psychologists and psychiatrists. Large follow-up studies are needed.

How fixed are child psychiatrists' views about ECT in the young?

The experience, knowledge, and attitudes of Australian and New Zealand child psychiatrists in relation to ECT in the young were surveyed in 2000 to ascertain whether their views had changed since a similar survey was conducted in 1996. Fifty-four percent (n = 129) of the original sample answered a mailed questionnaire. Psychiatrists in 2000 had greater self-rated level of knowledge on the subject and were less likely to base that knowledge on adult ECT data. Psychiatrists in 2000 were also more likely than in 1996 to approve the use of ECT in adolescents. The finding that the views of child psychiatrists can change is reassuring, given emerging data showing ECT in young persons to be an effective and safe treatment, and the requirement in various countries that child psychiatrists participate in the decision to administer the treatment. It is possible that a number of publications and presentations on the topic after the first survey contributed to the change in views. Nevertheless, there remain gaps in child psychiatrists' knowledge about ECT in the young that need to be addressed. The study findings should not be over interpreted because of the reduced response rate in the follow-up survey.

Has the practice and outcome of ECT in adolescents changed? findings from a whole-population study

OBJECTIVE

To investigate whether there were changes in the practice and outcome of electroconvulsive therapy (ECT) in adolescents in a whole population over a decade.

METHOD

All persons younger than 19 years who received ECT in the state of New South Wales, Australia, in the period from 1990 to 1999 were identified. Detailed information about diagnosis, treatment and outcome were then obtained.

RESULTS

Seventy-two patients aged 14-18 years underwent a total of 84 courses of ECT (1.53/100,000 adolescents were treated with ECT per year). In 1996 to 1999 compared with 1990 to 1995, there was an increase in ECT among females hospitalized involuntarily, EEG monitoring, stimulus dosing, bilateral ECT, and use of thiopentone. Overall, mood disorders derived most benefit from ECT while comorbid personality disorder predicted poorer short term outcome. Side effects were minor and transient.

CONCLUSIONS

The changes in ECT practice are consistent with changes in ECT practice generally over the survey period. The overall data on effectiveness and safety further support the treatment's use in young people.

Fluoxetine for acute treatment of depression in children and adolescents: a placebo-controlled, randomized clinical trial

BACKGROUND

This report presents results from the acute treatment phase of a clinical trial designed to confirm efficacy of a fixed dose of 20 mg of fluoxetine in children and adolescents with major depressive disorder (MDD).

METHOD

After a 3-week screening period, 122 children and 97 adolescents with MDD ( ) were randomly assigned to placebo or fluoxetine. After a 1-week placebo lead-in, fluoxetine-treated patients received fluoxetine 10 mg/day for 1 week, then fluoxetine 20 mg/day for 8 weeks.

RESULTS

Fluoxetine was associated with greater mean improvement in Children's Depression Rating Scale-Revised (CDRS-R) score than placebo after 1 week ( <.05) and throughout the study period. Significantly more fluoxetine-treated patients (41%) met the prospectively defined criteria for remission than did placebo-treated patients (20%) ( <.01). More fluoxetine- (65%) than placebo-treated (53%) patients met the prospectively defined response criterion of > or =30% decrease in CDRS-R score, but this difference was not significant ( =.093). Significantly more fluoxetine-than placebo-treated patients completed acute treatment ( =.001). There were no significant differences between treatment groups in discontinuations due to adverse events ( =.408).

CONCLUSION

Fluoxetine 20 mg daily appears to be well tolerated and effective for acute treatment of MDD in child and adolescent outpatients. Fluoxetine is the only antidepressant that has demonstrated efficacy in two placebo-controlled, randomized clinical trials of pediatric depression.

Clinical relevance of electroconvulsive therapy (ECT) in adolescents with severe mood disorder: evidence from a follow-up study

Given the limited knowledge on the long-term outcome of adolescents who receive electroconvulsive therapy (ECT), the study aimed to follow-up adolescents treated with ECT for severe mood disorder. Eleven subjects treated during adolescence with bilateral ECT for psychotic depression (n = 6) or mania (n = 5), and ten psychiatric controls matched for sex, age, school level, and clinical diagnosis, completed at least 1 year after treatment a clinical and social evaluation. Mean duration between time of index episode and time of follow-up evaluation was 5.2 years (range 2-9 years). At follow-up: (1) all patients except two in the control group received a diagnosis of bipolar disorder. (2) Fifteen patients had had more than one episode of mood disorder. (3) The two groups did not differ in social functioning nor school achievement. (4) Impact on school achievement was related to the severity of the mood disorder rather than ECT treatment. The results suggest that adolescents given ECT for bipolar disorder, depressed or manic, do not differ in subsequent school and social functioning from carefully matched controls.

Electroconvulsive therapy in adolescents: similarities to and differences from adults

OBJECTIVE

Information on the indications, technique, and effectiveness of electroconvulsive therapy (ECT) in adolescent patients is scarce. The recommendations for the use of ECT in this age group are similar to those in adults. This study compares the experience with ECT in the two age groups in the same community psychiatric institution, which adheres to the accepted protocols for diagnosis and treatment.

METHOD

The files of 24 consecutive adolescent patients treated in an ECT unit located in the center of Israel in the years 1991-1995 were retrospectively examined, and the findings were compared with those in 33 adult patients who started their ECT course on the same day. The technique for applying ECT was essentially the same in the two age groups.

RESULTS

ECT was equally effective for adolescents and adults (58% in each group achieved remission). The main difference was the diagnosis for which patients were referred: most of the adolescents were in the "psychotic spectrum, whereas most of the adults were in the "affective spectrum."

CONCLUSIONS

The findings support the current medical recommendations for the use of ECT in adolescents. Possible explanations for the differences in diagnosis between the two age groups are discussed.

Electroconvulsive therapy in adolescents with mood disorder: patients' and parents' attitudes

The aim of the study was to assess retrospectively patients' and parents' experiences and attitudes towards the use of electroconvulsive therapy (ECT) in adolescence. The experiences of subjects (n=10) who were administered ECT in adolescence for a severe mood disorder and their parents (n=18) were assessed using a semi-structured interview after a mean of 4.5 years (range, 19 months to 9 years). Their attitudes were mostly positive and ECT was considered a helpful treatment. Concerns were frequently expressed, probably because ECT was not fully understood by the patients and their families. Most complaints were of transitory memory impairment. The parents were satisfied with the consent procedure, while all but one patient did not remember the consent procedure. We concluded that, despite negative views about ECT in public opinion, adolescent recipients and their parents shared overall positive attitudes towards the use of ECT in this age range.

Electroconvulsive therapy for minors: experiences and attitudes of child psychiatrists and psychologists

OBJECTIVE

To estimate knowledge, experience, and attitudes towards the use of electroconvulsive treatment in minors (patients < 18 years of age), among child and adolescent psychiatrists and psychologists.

METHOD

1,600 questionnaires were mailed to a group of child and adolescent psychiatrists and psychologists.

RESULT

There were 625 (39%) respondents. 329 (53.8%) of the respondents stated that they possessed minimal knowledge about the use of ECT in children and adolescents. Lack of confidence in providing a second opinion was common and reported by 75%. Compared with those with minimal knowledge, respondents with advanced knowledge reported a higher perception of safety and efficacy. The majority (70%) of the respondents regarded ECT as a treatment of last resort.

CONCLUSION

Many child and adolescent psychiatrists and psychologists have very little knowledge, training, or experience in this treatment. They seem to be ill equipped to appropriately consider or advise patients and families about ECT. Clinical and research implications of these findings are discussed.

Subtypes of memory dysfunction associated with ECT: characteristics and neurobiological bases

Electroconvulsive therapy (ECT) is an effective treatment for a variety of psychiatric syndromes. However, one of its adverse secondary effects is neurocognitive dysfunction. The aim of this paper is to review different subtypes of memory dysfunction associated with ECT from a neuropsychological perspective. Declarative memory is clearly impaired after ECT. Immediate memory, however, is broadly preserved. Few studies have addressed procedural and incidental memory. Selective memory is impaired, probably due to the disruption of specific brain regions. Some of the possible neurobiological bases of ECT memory dysfunction are discussed in this paper. Synaptic plasticity, the cerebral neurotransmission system, and cerebral metabolism are examined in relation to the dysfunction and subsequent recovery of each memory subtype.

Pharmacological treatment of depression in children and adolescents

Major depression is a common disorder during childhood and adolescence. Over the past decade, many new antidepressants have been marketed in the US. In adults, these newer agents have been shown to be as effective as the prototypic tricyclic antidepressants (TCAs). Further, when compared with the TCAs these medications are better tolerated and are safer in overdose. Although TCAs are effective in the treatment of depressed adults, controlled clinical trials have not demonstrated their efficacy in either children or adolescents. In addition, concerns about the safety of TCAs and the monoamine oxidase inhibitors has left disappointingly few pharmacological treatment options available for depressed children and adolescents. For this reason, clinicians have begun to prescribe the newer agents for this population, despite the fact that relatively little is known about their disposition, safety or effectiveness in the young. Investigators have begun to examine whether the use of newer antidepressant medications such as fluoxetine, sertraline, paroxetine, fluvoxamine, nefazodone, and venlafaxine is truly indicated for children and adolescents with major depression. Pharmacokinetic studies of sertraline, paroxetine and nefazodone have been performed in depressed youths. The results of these studies have provided data for rational administration strategies for these agents. They have also provided evidence that these agents may be well tolerated in children and adolescents. Further evidence that these agents are often well tolerated when prescribed to depressed youths has been obtained from both open-label and double-blind studies. Published studies have generally shown that open-label treatment with these newer agents often leads to symptom amelioration in paediatric patients with major depression. Since high rates of placebo response are often seen in depressed children and adolescents, results from these studies cannot be interpreted to suggest that these medications have true antidepressant efficacy in this population. At present, the results of only two such studies have been published. The results of one of these trials are difficult to interpret because of methodological considerations. The other study reported that treatment with fluoxetine was superior to placebo. This paper critically reviews what has been published about the pharmacological treatment of depressed paediatric patients and provides some guidance to the use of antidepressants in this patient population, paying particular attention to what is known about the newer antidepressants as well as considering directions for future research.

Repetitive electroconvulsive seizures induce activity of c-Jun N-terminal kinase and compartment-specific desensitization of c-Jun phosphorylation in the rat brain

Electroconvulsive seizures (ECS) are used for therapy of pharmacoresistent depression and are supposed to induce long-lasting neuronal alterations in morphology and gene expression. In this study, we have investigated the phosphorylation of the transcription factor protein c-Jun at its serine 73 residue by immunohistochemistry and the activity of the c-Jun N-terminal kinase 1 (JNK1) by immunocomplex assay following repetitive ECS in adult rats. In untreated controls, nuclear c-Jun immunoreactivity, but not N-terminal phosphorylation, was present in a variety of neuronal populations including the hippocampus, the temporobasal cortex and the amygdalar complex. Daily ECS for 1, 5 or 10 days (1x, 5x or 10x ECS) did not alter the expression of c-Jun but caused a substantial N-terminal phosphorylation of c-Jun (phospho-c-Jun). Nuclear phospho-c-Jun immunoreactivity was maximal within 15 min following ECS, and became absent after 30 min. The highest levels of phospho-c-Jun labeling were found after 1x ECS in the amygdalar complex, the dorsomedial hypothalamus and the piriform cortex. The inducibility of c-Jun N-terminal phosphorylation was preserved in the medial amygdala and piriform cortex, but significantly declined in the basal amygdala and medial hypothalamus with progressive ECS stimulation. One single ECS 3 or 5 days following 10x ECS yielded a pattern of phospho-c-Jun as seen following 10x ECS; thus, a lag of 5 days was not sufficient to provoke the initial level of N-terminal phosphorylation of c-Jun. In the rostral hippocampus, c-Jun was not phosphorylated at any investigated time inspite of its high constitutive expression. In some contrast with this compartment-specific phosphorylation of c-Jun, immunocomplex assays revealed that the JNK1 activity was strongly enhanced in both amygdala and hippocampus. Our findings demonstrate that rapid JNK activation and phosphorylation of c-Jun as stand-by transcription factor characterize the beginning of neuroplastic changes, e.g., following ECS, a classic treatment of mental disorders. The N-terminal phosphorylation is compartment specific and can habituate following repetitive stimulation suggesting that the differential activation of the JNK/c-Jun axis is part of the neuronal strategy to integrate transynaptic excitation.