ECT for schizophrenia

Randomized, double-blind, sham-controlled trial to evaluate the efficacy and tolerability of electroconvulsive therapy in patients with clozapine-resistant schizophrenia

There is no established treatment for patients with clozapine-resistant schizophrenia (CRS). Clozapine augmentation strategies with antipsychotics or others substances are effective in comparison with placebo while and Electroconvulsive therapy (ECT) showed to be effective in comparison with treatment as usual (TAU) but not with placebo (sham-ECT). In the present double- blind randomized controlled trial, we compared 40 outpatients who received 20 sessions of ECT (n = 21) or sham-ECT (n = 19) (age = 37.40 ± 9.62, males = 77.5 %, illness duration = 14.95 ± 8.32 years, mean total Positive and Negative Syndrome Scale (PANSS) = 101.10 ± 24.91) who fulfilled well-defined CRS criteria including baseline clozapine plasma levels ≥350 ng/mL. The primary outcome was the ≥50 % PANSS Total Score reduction; secondary outcomes were the scores of the PANSS subscales, PANSS five-factor dimensions, PANSS-6 and the Calgary Depression Rating Scale (CDRS). Treatment response was analyzed by percentage reduction, Linear Mixed Models and effect sizes. At baseline both groups showed no differences except for years of school education (included as a covariate). At endpoint, only 1/19 of the completers (5.26 %) in the ECT group and 0/17 in the sham-ECT group showed a ≥50 % total PANSS score reduction. Both groups showed no significant differences of the total PANSS score (F = 0.12; p = 0.73), Positive (F = 0.27, p = 0.61), Negative (F = 0.25, p = 0.62), and General Psychopathology scores (F = 0.01, p = 0.94) as well for all PANSS five factors, the PANSS-6 and CDRS. Thus, the present study found no evidence that ECT is better than Sham-ECT in patients with CRS. Future sham-ECT controlled studies with larger sample sizes are warranted to test the efficacy of ECT for patients with CRS.

A prospective multicenter assessor-blinded randomized controlled study to compare the efficacy of short versus long protocols of electroconvulsive therapy as an augmentation strategy to clozapine in patients with ultra-resistant schizophrenia (SURECT study)

Background

Although clozapine is the most effective antipsychotic drug for treatment-resistant schizophrenia, it leads to a poor or partial response in 40 to 70% of patients. Augmentation of clozapine with electroconvulsive therapy (ECT) is a highly effective and relatively safe treatment for these clozapine-resistant patients. However, parameters are not yet well specified, such as the optimal number of sessions, their frequency, and the relevance of maintenance ECT. Our objective is to compare the efficacy and tolerance between two protocols of combined ECT and clozapine treatment in patients with ultra-resistant schizophrenia (URS): a 6-month protocol (short protocol with 20 ECT sessions) and a 12-month protocol (long protocol with 40 ECT sessions).

Methods

Sixty-four patients with schizophrenia with persistent psychotic symptoms despite clozapine treatment will be enrolled in a prospective multicentric assessor-blinded randomized controlled trial. Patients will be randomly assigned to the short or the long protocol. The main outcome is the response rate assessed by the Positive and Negative Symptoms Scale (PANSS) 3 months after the end of the treatment in patients following the long protocol compared to those following the short protocol. The response was defined as a 30% reduction on the PANSS baseline. Clinical assessments (PANSS, BPRS, HAMD-21, YMRS, CGI, GAF, Modified Overt Aggression Scale (MOAS), and Subjective Scale to Investigate Cognition in Schizophrenia (SSTICS)) and plasma clozapine concentration will be performed at baseline and at 2, 4, 6, 9, 12, and 15 months. Neuropsychological measures (MMSE, RL/RI-16, Doors test, D2 Test of Attention, Copy of the Rey-Osterrieth complex figure) will be performed at baseline and at 6 and 15 months.

Discussion

The aims of this research are to optimize protocols of combined ECT with clozapine in patients with URS and to offer specific recommendations for these patients’ care.

Trial registration

ClinicalTrials.gov NCT03542903. Registered on May 31, 2018. Id RCB: 2017-A02657-46

Electroconvulsive therapy: a review on indications, methods, risks and medication

This paper reviews and presents data of practical impact for those administering electroconvulsive therapy (ECT). In the first section, physical and physiological aspects of the stimulus as well as methods of stimulation are discussed. The second section deals with indications for ECT, efficacy and treatment modalities such as seizure duration, treatment frequency and total number of ECT applications. The last section is devoted to side effects, risks, comedication and comorbidity.

Electroconvulsive Therapy and Schizophrenia: A Systematic Review

Electroconvulsive therapy (ECT) is a remarkably effective treatment for major depressive disorder, but is less commonly utilized for treatment of psychotic disorders. Recent literature indicates that ECT can be a useful strategy for a wide range of psychotic disorders, including treatment-resistant schizophrenia. The purpose of this review is to examine the extant literature on ECT in schizophrenia with a primary focus on its efficacy, its impact on cognitive function, the role of maintenance ECT, and the potential role of neuroimaging biomarkers to provide more precise ECT treatment strategies. We evaluated the available literature, with a particular focus on prospective, randomized trials. Our review suggests that ECT can be an effective treatment strategy in this severely ill patient population. Studies suggest that while ECT in schizophrenia is a safe treatment modality, the potential for cognitive impairment must always be carefully weighed. The use and investigation of new biomarker strategies for the pharmacological treatment of schizophrenia, and the extension of these approaches to ECT are also discussed.

Electroconvulsive therapy for treatment-resistant schizophrenia

BACKGROUND

Electroconvulsive therapy (ECT) involves the induction of a seizure by the administration of an electrical stimulus via electrodes usually placed bilaterally on the scalp and was introduced as a treatment for schizophrenia in 1938. However, ECT is a controversial treatment with concerns about long-term side effects such a memory loss. Therefore, it is important to determine its clinical efficacy and safety for people with schizophrenia who are not responding to their treatment.

OBJECTIVES

Our primary objective was to assess the effects (benefits and harms) of ECT for people with treatment-resistant schizophrenia.Our secondary objectives were to determine whether ECT produces a differential response in people: who are treated with unilateral compared to bilateral ECT; who have had a long (more than 12 sessions) or a short course of ECT; who are given continuation or maintenance ECT; who are diagnosed with well-defined treatment-resistant schizophrenia as opposed to less rigorously defined treatment-resistant schizophrenia (who would be expected to have a greater affective component to their illness).

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Study-Based Register of Trials including clinical trial registries on 9 September 2015 and 4 August 2017. There were no limitations on language, date, document type, or publication status for the inclusion of records in the register. We also inspected references of all the included records to identify further relevant studies.

SELECTION CRITERIA

Randomised controlled trials investigating the effects of ECT in people with treatment-resistant schizophrenia.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data. For binary outcomes, we calculated the risk ratio (RR) and its 95% confidence intervals (CIs), on an intention-to-treat basis. For continuous data, we estimated the mean difference (MD) between the groups and its 95% CIs. We employed the fixed-effect model for all analyses. We assessed risk of bias for the included studies and created 'Summary of findings' tables using the GRADE framework.

MAIN RESULTS

We included 15 studies involving 1285 participants (1264 completers with an average age of 18 to 46 years) with treatment-resistant schizophrenia. We rated most studies (14/15, 93.3%) as at high risk of bias due to issues related to the blinding of participants and personnel. Our main outcomes of interest were: (i) clinically important response to treatment; (ii) clinically important change in cognitive functioning; (iii) leaving the study early; (iv) clinically important change in general mental state; (v) clinically important change in general functioning; (vi) number hospitalised; and (vii) death. No trial reported data on death.The included trials reported useable data for four comparisons: ECT plus standard care compared with sham-ECT added to standard care; ECT plus standard care compared with antipsychotic added to standard care; ECT plus standard care compared with standard care; and ECT alone compared with antipsychotic alone.For the comparison ECT plus standard care versus sham-ECT plus standard care, only average endpoint BPRS (Brief Psychiatric Rating Scale) scores from one study were available for mental state; no clear difference between groups was observed (short term; MD 3.60, 95% CI -3.69 to 10.89; participants = 25; studies = 1; very low-quality evidence). One study reported data for service use, measured as number readmitted; there was a clear difference favouring the ECT group (short term; RR 0.29, 95% CI 0.10 to 0.85; participants = 25; studies = 1; low-quality evidence).When ECT plus standard care was compared with antipsychotics (clozapine) plus standard care, data from one study showed no clear difference for clinically important response to treatment (medium term; RR 1.23, 95% CI 0.95 to 1.58; participants = 162; studies = 1; low-quality evidence). Clinically important change in mental state data were not available, but average endpoint BPRS scores were reported. A positive effect for the ECT group was found (short-term BPRS; MD -5.20, 95% CI -7.93 to -2.47; participants = 162; studies = 1; very low-quality evidence).When ECT plus standard care was compared with standard care, more participants in the ECT group had a clinically important response (medium term; RR 2.06, 95% CI 1.75 to 2.42; participants = 819; studies = 9; moderate-quality evidence). Data on clinically important change in cognitive functioning were not available, but data for memory deterioration were reported. Results showed that adding ECT to standard care may increase the risk of memory deterioration (short term; RR 27.00, 95% CI 1.67 to 437.68; participants = 72; studies = 1; very low-quality evidence). There were no clear differences between groups in satisfaction and acceptability of treatment, measured as leaving the study early (medium term; RR 1.18, 95% CI 0.38 to 3.63; participants = 354; studies = 3; very low-quality evidence). Only average endpoint scale scores were available for mental state (BPRS) and general functioning (Global Assessment of Functioning). There were clear differences in scores, favouring ECT group for mental state (medium term; MD -11.18, 95% CI -12.61 to -9.76; participants = 345; studies = 2; low-quality evidence) and general functioning (medium term; MD 10.66, 95% CI 6.98 to 14.34; participants = 97; studies = 2; very low-quality evidence).For the comparison ECT alone versus antipsychotics (flupenthixol) alone, only average endpoint scale scores were available for mental state and general functioning. Mental state scores were similar between groups (medium-term BPRS; MD -0.93, 95% CI -6.95 to 5.09; participants = 30; studies = 1; very low-quality evidence); general functioning scores were also similar between groups (medium-term Global Assessment of Functioning; MD -0.66, 95% CI -3.60 to 2.28; participants = 30; studies = 1; very low-quality evidence).

AUTHORS' CONCLUSIONS

Moderate-quality evidence indicates that relative to standard care, ECT has a positive effect on medium-term clinical response for people with treatment-resistant schizophrenia. However, there is no clear and convincing advantage or disadvantage for adding ECT to standard care for other outcomes. The available evidence was also too weak to indicate whether adding ECT to standard care is superior or inferior to adding sham-ECT or other antipsychotics to standard care, and there was insufficient evidence to support or refute the use of ECT alone. More good-quality evidence is needed before firm conclusions can be made.

Impacts of Electroconvulsive Therapy on 1-Year Outcomes in Patients With Schizophrenia: A Controlled, Population-Based Mirror-Image Study

OBJECTIVES

Despite the decline in the use of electroconvulsive therapy (ECT) in patients with schizophrenia, ECT augmentation is still recommended for those with poor response to standard pharmacological intervention. However, the effectiveness of augmentation of antipsychotics with ECT on long-term clinical outcomes needs to be verified in an expanded sample.

METHODS

Patients who were hospitalized for schizophrenia and received ECT for the first time during that hospitalization were identified from the total population health insurance database in Taiwan between 2002 and 2011. A comparison group was randomly selected and matched by age, gender, calendar year of hospitalization, and duration of hospitalization. Using a mirror-image design, the changes in rates of psychiatric and overall hospitalization, length of hospital stay, number of emergency department visits, and direct medical costs across the 1-year pre- and post-treatment periods were examined.

RESULTS

A total of 2074 patients with the same number of comparison participants were included in the analysis. The rate of re-hospitalization decreased significantly in the ECT group during the 1-year post-treatment period, while there was no significant difference in the comparison group. Correspondingly, the total medical expenses increased significantly in the non-ECT group, but not in the ECT group. Notably, the reduction in the psychiatric re-hospitalization rate in the ECT group was more pronounced among those treated with clozapine or a medium-high average daily dose of antipsychotics.

CONCLUSION

This 1-year mirror-image analysis indicated that augmentation of antipsychotics with ECT in schizophrenic patients was associated with a reduced rate of psychiatric re-hospitalization.

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the management of schizophrenia and related disorders

OBJECTIVES

This guideline provides recommendations for the clinical management of schizophrenia and related disorders for health professionals working in Australia and New Zealand. It aims to encourage all clinicians to adopt best practice principles. The recommendations represent the consensus of a group of Australian and New Zealand experts in the management of schizophrenia and related disorders. This guideline includes the management of ultra-high risk syndromes, first-episode psychoses and prolonged psychoses, including psychoses associated with substance use. It takes a holistic approach, addressing all aspects of the care of people with schizophrenia and related disorders, not only correct diagnosis and symptom relief but also optimal recovery of social function.

METHODS

The writing group planned the scope and individual members drafted sections according to their area of interest and expertise, with reference to existing systematic reviews and informal literature reviews undertaken for this guideline. In addition, experts in specific areas contributed to the relevant sections. All members of the writing group reviewed the entire document. The writing group also considered relevant international clinical practice guidelines. Evidence-based recommendations were formulated when the writing group judged that there was sufficient evidence on a topic. Where evidence was weak or lacking, consensus-based recommendations were formulated. Consensus-based recommendations are based on the consensus of a group of experts in the field and are informed by their agreement as a group, according to their collective clinical and research knowledge and experience. Key considerations were selected and reviewed by the writing group. To encourage wide community participation, the Royal Australian and New Zealand College of Psychiatrists invited review by its committees and members, an expert advisory committee and key stakeholders including professional bodies and special interest groups.

RESULTS

The clinical practice guideline for the management of schizophrenia and related disorders reflects an increasing emphasis on early intervention, physical health, psychosocial treatments, cultural considerations and improving vocational outcomes. The guideline uses a clinical staging model as a framework for recommendations regarding assessment, treatment and ongoing care. This guideline also refers its readers to selected published guidelines or statements directly relevant to Australian and New Zealand practice.

CONCLUSIONS

This clinical practice guideline for the management of schizophrenia and related disorders aims to improve care for people with these disorders living in Australia and New Zealand. It advocates a respectful, collaborative approach; optimal evidence-based treatment; and consideration of the specific needs of those in adverse circumstances or facing additional challenges.

Transcranial magnetic stimulation, transcranial direct current stimulation and electroconvulsive therapy for medication-resistant psychosis of schizophrenia

PURPOSE OF REVIEW

Despite adequate antipsychotic treatment, 20-30% of patients with schizophrenia fail to obtain remission from psychosis. Physical stimulation treatments may provide an alternative therapy. In this review, we summarize the most recent studies regarding repetitive transcranial magnetic stimulation (rTMS), transcranial direct current stimulation (tDCS) and electroconvulsive therapy (ECT) for medication-resistant psychosis in schizophrenia.

RECENT FINDINGS

Stimulation techniques in the treatment of medication-resistant psychosis have shown inconsistent results. Initial results of rTMS for auditory verbal hallucinations (AVH) were promising, but three recent large randomized controlled trials (RCTs) show similar results of rTMS as placebo. tDCS has shown initial promise as a treatment for AVH, but only in case studies and in two small RCTs. Larger studies are needed to define its efficacy. Although psychotic symptoms generally decrease after ECT, its efficacy has not been demonstrated in comparison with placebo.

SUMMARY

Although previous meta-analyses indicate significant mean effect sizes for rTMS for intractable AVH, three recent large RCTs indicate no effect compared with placebo. The use of tDCS for resistant AVH and ECT for intractable psychosis has shown some initial promise, but adequately sized placebo-controlled RCTs are now needed. Taken together, the evidence for physical stimulation techniques to relieve medication-resistant psychosis is currently weak.

Schizophrenia: An Overview

An overview of schizophrenia is presented. The epidemiology and clinical features of this common but serious psychiatric disorder are outlined. Four case vignettes illustrate different presentations and, to some extent, the varying course of the disorder. Diagnostic issues are discussed and the heterogeneity of the disorder highlighted. The major aetiological hypotheses are outlined, including evidence for genetic and biochemical involvement, the role of family, social and personality factors, psychological mechanisms and life events. A diathesis-stress view is presented, in which biological vulnerability and psychological and environmental factors are necessary for the development of the clinical disorder. Somatic and psychosocial treatments are briefly discussed as are the course, possible outcomes and factors affecting prognosis. Finally some future research directions in both the biological and psychosocial areas are considered.

Indications for electroconvulsive treatment in schizophrenia: a systematic review

BACKGROUND

Electroconvulsive therapy (ECT) is a medical treatment that is most effective for mood disorders (Bipolar Disorder and Major Depression). It has also been shown to be an effective treatment for schizophrenia accompanied by catatonia, extreme depression, mania and other affective components. ECT is currently under-used in many psychiatric settings due to its stigmatized perception by patients and mental health professionals. However, many unanswered questions remain regarding its role in the management of patients with schizophrenia.

AIM

Evaluate the main indications of ECT in subjects suffering from schizophrenia.

OBJECTIVES

Investigate the efficacy and the main indications of ECT in the treatment of schizophrenic patients, evaluate its effects in the short-term and the long-term, compare ECT treatment with pharmacotherapy, and assess the effects of treatment with ECT.

METHODS

A systematic review of the literature was conducted on the use of ECT for schizophrenia. Thirty one articles from peer-reviewed journals were identified, and the most relevant articles were selected for this review.

RESULTS

The most common indication for using ECT for schizophrenia patients was to augment pharmacotherapy, while the most common accompanying symptoms were, in order, catatonia, aggression and suicide. Catatonic patients responded significantly better to ECT than patients with any other subtype of schizophrenia. The combination of ECT with pharmacotherapy can be useful for drug-resistant patients. The use of an ECT-risperidone combination or ECT-clozapine combination in patients non-responsive to prior pharmacotherapy was found to be most effective.

CONCLUSIONS

This review indicates that ECT, combined with pharmacotherapy, may be a viable option for a selected group of patients with schizophrenia. In particular, the use of ECT is recommended for drug-resistant patients, for schizophrenic patients with catatonia, aggression or suicidal behavior, and when rapid global improvement and reduction of acute symptomatology are required.

Using ECT in schizophrenia: a review from a clinical perspective

OBJECTIVES

Despite the fact that many studies have addressed the use of ECT in schizophrenia questions on clinical use remain poorly answered and clinical application is largely based on data originating from depressed patients.

METHODS

We review data on the use of ECT in schizophrenic patients drawn from original studies indicated by a Pubmed search and referenced in recent and older expert reviews with a specific focus on four issues: symptom response, technical application, continuation/maintenance ECT and combination with medication.

RESULTS

Catatonic patients are the most responsive. Positive symptoms such paranoid delusions and affective symptoms follow. There are indications that ECT may improve responsivity to medication. No particular technical features stand out in studies except lengthier courses, but not for catatonia. Combination with medication appears to be preferable over either treatment alone and effective combination particularly with clozapine is supported by data. Use of continuation and maintenance treatments in responders appears beneficial.

CONCLUSION

Certain schizophrenic patients may benefit significantly from the use of ECT. More specific research is required to address particular questions.

Why do we prescribe ECT to schizophrenia patients?

Electroconvulsive therapy (ECT) is prescribed for schizophrenia patients for various indications, in our country. However, official guidelines in other countries have been cautious in prescribing ECT for schizophrenia. To study the indications for which patients with schizophrenia receive ECT. We studied records of schizophrenia inpatients receiving ECT in one year (2005) (n=101) retrospectively, as well as the consecutive data of patients between May 2007 and June 2008 (n=101) prospectively. The various indications for ECT in schizophrenia were studied by frequency analysis. Of the 202 schizophrenia patients who received ECT, the most common reason was 'to augment pharmacotherapy' in (n=116) cases. The target symptoms for which ECT was prescribed the most was catatonia (n=72). The mean number of ECTs (SD) received was 8.4 (2.8). Augmentation of pharmacotherapy was the most common indication of ECT in patients with schizophrenia.

Does electroconvulsive therapy cause brain damage?

Although the use of ECT has declined dramatically from its inception, this decrease has recently shown signs of leveling out because of ECT's powerful therapeutic effect in severely ill depressed individuals who either do not respond to pharmacologic alternatives or are too ill to tolerate a relatively lengthy drug trial. Notwithstanding its therapeutic benefits, ECT has also remained a controversial treatment modality, particularly in the eye of the public. Given the unsavory qualities associated with the word “electroconvulsive,” claims of possible, probable, or even certain brain damage with ECT have easily found listeners. A careful, nonselective assessment of data covering the areas of pathology, radiology, electrophysiology, biochemistry, and neuropsychology leads both to certain conclusions and to certain unanswered questions. ECT is not the devastating purveyor of wholesale brain damage that some of its detractors claim. For the typical individual receiving ECT, no detectable correlates of irreversible brain damage appear to occur. Still, there remains the possibility that either subtle, objectively undetectable persistent deficits, particularly in the area of autobiographic memory function, occur, or that a rarely occurring syndrome of more pervasive persistent deficits related to ECT use may be present. Clearly, more research directed toward answering these questions needs to be carried out so that the role of ECT can be more rigorously defined. While such research is pending, however, we cannot expect that the conditions that predispose to clinical referrals for ECT will disappear. Given the misery, anguish, and risk of death by suicide, starvation, or debilitation associated with severe depressive illness, for example, it still appears that ECT, at least for the present, must continue to be available.

Concurrent administration of clozapine and electroconvulsive therapy in clozapine-resistant schizophrenia

OBJECTIVE

The aim of this article is to critically review all published studies regarding the efficacy and safety of the concurrent administration of clozapine (CLZ) and electroconvulsive therapy (ECT) in CLZ-resistant schizophrenic or schizoaffective patients.

METHOD

A MEDLINE search from January 1980 to July 2005 was conducted.

RESULTS

One open-label trial and 6 case studies were located, comprising 21 schizophrenic and 1 schizo affective patients (12 men and 10 women) with a mean age of 41.9 years. The duration and dosage of CLZ monotherapy before ECT were reported at least 12 weeks and 300 mg/d, respectively, in 10 patients (45.4%). Plasma CLZ levels before ECT were assessed in 12 patients (54.5%), in which only 7 (31.8%) were reported to be higher than 350 ng/mL. The CLZ dosage during ECT ranged from 200 to 900 mg/d (mean, 518.2 +/- 203.3 mg/d). The number of ECT sessions ranged from 2 to 20 (mean, 11.5 +/- 5.4). Application of electrodes was unilateral in 7 patients, bilateral in 10 patients, and mixed in 2 patients. Sixteen patients (72.7%) showed marked improvement whereas 6 patients (27.3%) had moderate, minimal, or no improvement. No predictors of outcome could be isolated. Side effects reported by 5 patients (22.7%) were nausea, tachycardia, hypertension, memory problems, and confusion. Ten patients (45.4%) relapsed during follow-up. Substantial improvement persisted beyond 4 months in only 5 patients (22.7%).

CONCLUSION

Preliminary evidence exists for the safety and short-term efficacy of the concurrent administration of CLZ and ECT in CLZ-resistant schizophrenic or schizoaffective patients.

Combined use of electroconvulsive therapy and antipsychotics in schizophrenia: the Indian evidence. A review and a meta-analysis

BACKGROUND

Combined use of electroconvulsive therapy (ECT) and antipsychotics in acute phases of schizophrenia remains controversial and inadequately investigated.

AIM

This study tried to examine whether the ECT-antipsychotic combination was more efficacious than antipsychotic drugs used alone in the acute phase treatment of schizophrenia, by way of an open review and an exploratory meta-analysis of the Indian studies on the subject.

METHOD

Eleven studies (n = 651) and 4 controlled trials (n = 113) were selected for the open review and the meta-analysis, respectively. For the meta-analysis, a standard chi analysis was undertaken to check for heterogeneity. Brief Psychiatric Rating Scale scores were used to estimate treatment effects.

RESULTS

The open review suggested that the ECT-antipsychotic combination was more efficacious than antipsychotic drugs used alone in the first few weeks of treatment of schizophrenia. The meta-analysis, using the Inverse Weighted Variance Model, showed that the ECT-antipsychotic combination provides an advantage of approximately 5 Brief Psychiatric Rating Scale points over antipsychotic drugs, in the first 4 to 5 weeks of treatment of schizophrenia (mean treatment effect, 4.89; 95% confidence intervals, 0.50-9.38).

CONCLUSIONS

The studies reviewed thus indicated that ECT-antipsychotic combinations might be better than antipsychotic drugs used alone in the first few weeks of treatment of schizophrenia; the main benefit seemed to be an acceleration of treatment response. Although the evidence was not conclusive because of several methodological difficulties, it does suggest that further research is required to determine the usefulness of the ECT-antipsychotic combination in the acute treatment of schizophrenia.

Evidências da eficácia da eletroconvulsoterapia na prática psiquiátrica

A eletroconvulsoterapia (ECT) consiste em tratamento biológico ainda não amplamente utilizado na prática psiquiátrica, devido aos inúmeros fatores que contribuem para uma resistência acerca do método. Objetivando sustentar, com embasamento científico, o emprego da ECT, agregamos evidências de sua eficácia, indicações, contra-indicações e efeitos adversos, advindas dos principais ensaios clínicos randomizados e meta-análises disponíveis na literatura médica atual sobre o tema (PubMed/MEDLINE, Cochrane).

The combined use of electroconvulsive therapy and antipsychotics in patients with schizophrenia

OBJECTIVES

We sought to review the literature on the use of combined antipsychotic medications and electroconvulsive therapy (ECT) for the treatment of schizophrenia, with regard to efficacy, side effects, and ECT technique.

METHODS

A computerized search of the literature published from 1980 to 2004 was conducted on Medline and PsychoInfo using the words schizophrenia, antipsychotic, neuroleptic, psychotropic, and ECT. Only studies including patients with the diagnosis of schizophrenia were included.

RESULTS

We identified 42 articles including 1371 patients. The majority of the reports consist of uncontrolled studies (n = 31), mostly with typical antipsychotics (n = 23). Results from open studies suggest that the combination of ECT and antipsychotics is a very useful and safe strategy for the treatment of refractory schizophrenia. Double-blind controlled studies (n = 8) were inconclusive. Twelve articles were on the combination of clozapine and ECT. Initial concerns about the safety of the coadministration of clozapine and ECT were not substantiated, but despite the auspicious results from several case reports and 2 open trials, this combination remains understudied. Most studies preferred the bitemporal placement (n = 28), but because of insufficient data derived from direct comparisons, no conclusion on placement superiority can be reached. One study indicates that with the bilateral placement higher electrical dosages yields faster responses in this population.

CONCLUSIONS

The body of the data provided by research is still insufficient to allow definitive conclusions on the combination of antipsychotics and ECT. However, the literature reviewed indicates that the combination is a safe and efficacious treatment strategy for patients with schizophrenia, especially those refractory to conventional treatments.

Electroconvulsive therapy for schizophrenia

BACKGROUND

Electroconvulsive therapy (ECT) involves the induction of a seizure for therapeutic purposes by the administration of a variable frequency electrical stimulus shock via electrodes applied to the scalp. The effects of its use in people with schizophrenia are unclear.

OBJECTIVES

To determine whether electroconvulsive therapy (ECT) results in clinically meaningful benefit with regard to global improvement, hospitalisation, changes in mental state, behaviour and functioning for people with schizophrenia, and to determine whether variations in the practical administration of ECT influences outcome.

SEARCH STRATEGY

We undertook electronic searches of Biological Abstracts (1982-1996), EMBASE (1980-1996), MEDLINE (1966-2004), PsycLIT (1974-1996),SCISEARCH (1996) and the Cochrane Schizophrenia Group's Register (July 2004). We also inspected the references of all identified studies and contacted relevant authors.

SELECTION CRITERIA

We included all randomised controlled clinical trials that compared ECT with placebo, 'sham ECT', non-pharmacological interventions and antipsychotics and different schedules and methods of administration of ECT for people with schizophrenia, schizoaffective disorder or chronic mental disorder.

DATA COLLECTION AND ANALYSIS

Working independently, we selected and critically appraised studies, extracted data and analysed on an intention-to-treat basis. Where possible and appropriate we calculated risk ratios (RR) and their 95% confidence intervals (CI) with the number needed to treat (NNT). For continuous data Weighted Mean Differences (WMD) were calculated. We presented scale data for only those tools that had attained pre-specified levels of quality. We also undertook tests for heterogeneity and publication bias.

MAIN RESULTS

This review includes 26 trials with 50 reports. When ECT is compared with placebo or sham ECT, more people improved in the real ECT group (n=392, 10 RCTs, RR 0.76 random CI 0.59 to 0.98, NNT 6 CI 4 to 12) and though data were heterogeneous (chi-square 17.49 df=9 P=0.04), its impact on variability of data was not substantial (I-squared 48.5%). There was a suggestion that ECT resulted in less relapses in the short term than sham ECT (n=47, 2 RCTs, RR fixed 0.26 CI 0.03 to 2.2), and a greater likelihood of being discharged from hospital (n=98, 1 RCT, RR fixed 0.59, CI 0.34 to 1.01). There is no evidence that this early advantage for ECT is maintained over the medium to long term. People treated with ECT did not drop out of treatment earlier than those treated with sham ECT (n=495, 14 RCTs, RR fixed 0.71 CI 0.33 to 1.52, I-squared 0%). Very limited data indicated that visual memory might decline after ECT compared with sham ECT (n=24, 1 RCT, WMD -14.0 CI -23 to -5); the results of verbal memory tests were equivocal. When ECT is directly compared with antipsychotic drug treatments (total n=443, 10 RCTs) results favour the medication group (n=175, 3 RCTs, RR fixed 'not improved at the end of ECT course' 2.18 CI 1.31 to 3.63). Limited evidence suggests that ECT combined with antipsychotic drugs results in greater improvement in mental state (n= 40, 1 RCT, WMD, Brief Psychiatric Rating Scale -3.9 CI - 2.28 to -5.52) than with antipsychotic drugs alone. One small study suggested more memory impairment after a course of ECT combined with antipsychotics than with antipsychotics alone (n=20, MD serial numbers and picture recall -4.90 CI -0.78 to -9.02), though this proved transient. When continuation ECT was added to antipsychotic drugs, the combination was superior to the use of antipsychotics alone (n=30, WMD Global Assessment of Functioning 19.06 CI 9.65 to 28.47), or CECT alone (n=30, WMD -20.30 CI -11.48 to -29.12). Unilateral and bilateral ECT were equally effective in terms of global improvement (n=78, 2 RCTs, RR fixed 'not improved at end of course of ECT' 0.79 CI 0.45 to 1.39). One trial showed a significant advantage for 20 treatments over 12 treatments for numbers globally improved at the end of the ECT course (n=43, RR fixed 2.53 CI 1.13 to 5.66).

AUTHORS' CONCLUSIONS

The evidence in this review suggests that ECT, combined with treatment with antipsychotic drugs, may be considered an option for people with schizophrenia, particularly when rapid global improvement and reduction of symptoms is desired. This is also the case for those with schizophrenia who show limited response to medication alone. Even though this initial beneficial effect may not last beyond the short term, there is no clear evidence to refute its use for people with schizophrenia. The research base for the use of ECT in people with schizophrenia continues to expand, but even after more than five decades of clinical use, there remain many unanswered questions regarding its role in the management of people with schizophrenia.

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.

A role for glia in the action of electroconvulsive therapy

In this article, we consider possible mechanisms of action for electroconvulsive therapy (ECT) based on evidence regarding cellular changes in affective and psychotic illnesses. Postmortem investigations of major depression and schizophrenia have revealed abnormalities in the number of neuronal and glial cells. Such cellular changes could indicate a perturbed balance between neurogenesis and neuronal death in the adult brain. Psychotropic drugs and ECT have been shown to stimulate neurogenesis, giving rise to the hypothesis that this generation of new cells mediates some of their therapeutic effect. A possible trophic effect on glial cells has not been examined. Since glial cells are essential for proper neuronal function, treatments that alter glial function would have significant effects on brain function. We suggest that the effectiveness of ECT is, in part, related to its effect on glial cells. This testable hypothesis may advance our understanding and treatment of psychiatric disorders.

Electroconvulsive therapy for schizophrenia

BACKGROUND

Electroconvulsive therapy (ECT) involves the induction of a seizure (fit) for therapeutic purposes by the administration of a variable frequency electrical stimulus shock via electrodes applied to the scalp. The effects of its use in people with schizophrenia are unclear.

OBJECTIVES

To determine whether electroconvulsive therapy (ECT) results in clinically meaningful benefit with regard to global improvement, hospitalisation, changes in mental state, behaviour and functioning for people with schizophrenia, and whether variations in the practical administration of ECT influences outcome.

SEARCH STRATEGY

Electronic searches of Biological Abstracts (1982-1996), EMBASE (1980-1996), MEDLINE (1966-2001), PsycLIT (1974-1996),SCISEARCH (1996) and the Cochrane Schizophrenia Group's Register (July 2001) were undertaken. The references of all identified studies were also inspected and authors contacted.

SELECTION CRITERIA

All randomised controlled clinical trials that compared ECT with placebo, 'sham ECT', non-pharmacological interventions and antipsychotics, and different schedules and methods of administration of ECT for people with schizophrenia, schizoaffective disorder or chronic mental disorder.

DATA COLLECTION AND ANALYSIS

Studies were reliably selected, quality rated and data extracted. For dichotomous data, relative risks (RR) were estimated, with the 95% confidence intervals (CI). Where possible, the number needed to treat statistic (NNT) was calculated. Analysis was by intention-to-treat. Normal continuous data was summated using the weighted mean difference (WMD). Scale data was presented for only those tools that had attained pre-specified levels of quality. Tests of heterogeneity and for publication bias were undertaken.

MAIN RESULTS

This review includes 24 trials with 46 reports. When ECT is compared with placebo or sham ECT, fewer people remain unimproved in the real ECT group (n=400, RR fixed 'not globally improved in the short term' 0.77 CI 0.6 to 0.9, chi-square 13.46 df=8 p=0.1). Removal of the one study with clearly heterogeneous results causes a change in the findings (n=380, 8 RCTs, RR fixed 0.83 CI 0.7 to 1.01), as does removal of a clinically heterogeneous trial (n=370, 8 RCTs, RR fixed 0.74 CI 0.6 to 0.9, chi-square 10.97 df=7 p=0.14). There was a suggestion that ECT resulted in less relapses than sham ECT (n=47, 2 RCTs, RR fixed 0.26 CI 0.03 to 2.2), and a greater likelihood of being discharged from hospital (n=98, 1 RCT, RR fixed 0.59, CI 0.34 to 1.01). There is no evidence that this early advantage for ECT is maintained over the medium to long term. People treated with ECT did not drop out of treatment earlier than those treated with sham ECT (n=495, 14 RCTs, RR fixed 0.71 CI 0.33 to 1.52). Very limited data indicated that visual memory might decline after ECT compared with sham ECT (n=24, 1 RCT, WMD -14.0 CI -23 to -5); the results of verbal memory tests were equivocal. When ECT is directly compared with antipsychotic drug treatment (total n=419, 8 RCTs), results favour the medication group (n=175, 3 RCTs, RR fixed 'not improved at the end of ECT course' 2.18 CI 1.3 to 3.6). One small study suggested more memory impairment after a course of ECT combined with antipsychotics than with antipsychotics alone (n=20, MD serial numbers and picture recall -4.90 CI -0. 8 to -9), though this proved transient. When continuation ECT was added to antipsychotic drugs, the combination was superior to the use of antipsychotics alone (n=30, WMD Global Assessment of Functioning 19.1 CI 9.7 to 28.5), or CECT alone (n=30, WMD -20.3 CI -11.5 to -29.1). Unilateral and bilateral ECT were equally effective in terms of global improvement (n=78, 2 RCTs, RR fixed 'not improved at end of course of ECT' 0.79 CI 0.5 to 1.4). One trial showed a significant advantage for 20 treatments over 12 treatments for numbers globally improved at the end of the ECT course (n=43, RR fixed 2.53 CI 1.1 to 5.7).

REVIEWER'S CONCLUSIONS

There is no evidence to clearly refute the use of ECT for people with schizophrenia. There is some limited evidence to support its use, particularly combined with antipsychotic drugs for those with schizophrenia who show limited response to medication alone. The research base for the use of ECT in people with schizophrenia is growing but, even after more than five decades of clinical use, is still inadequate.

Combined ECT and neuroleptic therapy in treatment-refractory schizophrenia: prediction of outcome

There have been scanty reports of the clinical features of schizophrenic patients treated with electroconvulsive therapy (ECT). This prospective study examined clinical characteristics and predictive factors associated with therapeutic outcome. Two hundred and ninety-three patients with refractory schizophrenia were treated with a combination of ECT and flupenthixol. Outcome assessments included the Brief Psychiatric Rating Scale (BPRS), the Global Assessment of Functioning (GAF), and the Mini-Mental State Examination (MMSE). One hundred and sixty patients (54.6%) met a response criterion. The responders were younger, had shorter durations of illness and current episode, more admissions, and less family history of schizophrenia. The duration of current episode (t=5.0, P<0.0001), followed by baseline GAF score (t=3.1, P=0.002), duration of illness (t=3.1, P=0.002), baseline MMSE score (t=3.0, P=0.003), duration of the previously failed neuroleptic trials (t=3.0, P=0.003), family history of schizophrenia (t=2.1, P=0.03), and paranoid type (t=2.1, P=0.04), could predict the therapeutic outcome. Treatment resulted in marked improvement in positive symptoms but had a minimal effect or led to a worsening of negative symptoms.

Factors influencing treatment frequency of continuation ECT in schizophrenia

Although continuation and maintenance electroconvulsive therapy (C-ECT and M-ECT) have been used since 1943, no studies reported data that might help guide the selection of C-ECT frequency. This two-phase study was conducted in 32 chronic schizophrenic patients, with history of prior responsiveness to ECT to determine clinical variables associated with treatment frequency of C-ECT. After acute combination treatment with ECT and neuroleptics (Phase I), all patients received weekly ECT during the first 4 weeks of C-ECT (Phase II). They were then assigned to receive either weekly (n = 8) or biweekly (n = 24) ECT, depending on the history of their prior responsiveness to C-/M-ECT and their Brief Psychiatric Rating Scale (BPRS) scores. At the third month, patients with biweekly ECT were assigned to receive either biweekly (n = 17) or triweekly ECT (n = 7) following the same criteria. The duration of Phase II was 6 months. Onset of illness, numbers of admission, educational level, duration of trials of the previously failed neuroleptics, BPRS scores, and percentage of reductions in BPRS scores at the end of Phase I, Global Assessment of Functioning (GAF) scores at the end of Phase I, Mini-Mental State Exam (MMSE) scores at Phase I entry and Phase I end, and GAF and MMSE scores during the first month of Phase II showed a differentiation between patients having weekly treatment versus biweekly treatment. Whereas a history of previously failed flupenthixol treatment, dosage of flupenthixol used in this study, and MMSE scores at the end of Phase I and during the first month of Phase II showed a differentiation between patients having biweekly C-ECT versus triweekly C-ECT. Our results suggest that the better the prognostic factors for each patient, the longer the frequency of C-ECT.

Polyamine oxidase activity in sera of depressed and schizophrenic patients after ECT treatment

High level of polyamine oxidase activity is detected in sera of depressed as well as in schizophrenic patients. ECT treatment of depressed and schizophrenic patients reduced significantly the level of polyamine oxidase activity in their sera. After ECT treatment, clinically improved depressed and schizophrenic subjects were found to have sera polyamine oxidase activity not significantly differ from that of normal subjects. Possible biochemical mechanisms, which link polyamine oxidase activity, schizophrenia, depression and ECT effect are discussed here.

Effectiveness of ECT combined with risperidone against aggression in schizophrenia

Aggressive behavior in schizophrenic patients can often be problematic not only for the patients themselves, but for their families and others. This study examined the effect of electroconvulsive therapy (ECT) in combination with risperidone in an open trial in 10 male schizophrenic patients with significant aggressive behaviors. Patients were given bilateral ECT five times a week in combination with risperidone. The mean total number of times of ECT was 6.6 (range 5-9). The aggressive behavior in five of the six patients, who showed positive symptoms, was rapidly ameliorated within 12 days. The ECT/risperidone regimen also eliminated aggressive behavior in four patients showing no positive symptoms within 10 days. These treatment effects lasted for at least 6 months in 9 (of the 10) patients. The results suggest that ECT, combined with risperidone, produce a rapid and effective elimination of aggressive behaviors in schizophrenic patients. In addition, there was a resolution of aggression in four patients with no positive symptoms. This suggests that aggression in some schizophrenic patients develops as a primary symptom of schizophrenia and is not related to other positive symptoms of the disease or the patient's personality traits.

Management of treatment resistant schizophrenia unresponsive to clozapine

A recent challenge in schizophrenia has been the management of patients who have failed to respond not only to standard therapeutic regimes but also to trials of atypical neuroleptics such as clozapine and risperidone. This article focuses on the further psychological and pharmacological management of such patients.

Combined chlorpromazine and electroconvulsive therapy in mania

We report the efficacy of combined chlorpromazine and electroconvulsive therapy (ECT) in the treatment of mania. Two groups of 15 manic patients received eight ECT sessions either actual or simulated, in a double-blind, controlled study. All patients also received 600 mg of chlorpromazine daily until the sixth session. Results indicate that the group receiving the combination of chlorpromazine and ECT did significantly better than the other group.

The use of high-dose antipsychotic medication

Antipsychotic medication is the mainstay of treatment for the functional psychotic illnesses. Such drugs are also referred to as neuroleptics (meaning a drug with both antipsychotic effects and effects on movement) and major tranquillisers. The psychotic illnesses for which they are prescribed include schizophrenia, mania in the course of a bipolar mood disorder, and, more rarely, depression accompanied by psychotic symptoms. These are not uncommon illnesses. At some time during their lives approximately 1% of the population will suffer at least one episode of schizophrenia and a further 1% will suffer at least one episode of mania. During an episode some patients, but by no means all, suffer extreme changes in their thinking, mood and behaviour which can be very distressing to experience and which can make patients a danger to themselves or other people.

Electroconvulsive therapy

The following position paper was approved by the Board of Directors of the Canadian Psychiatric Association on September 15,1992.

Proposals for the mechanism of action of convulsive therapy: a synthesis

The convulsive therapies have been powerful additions to somatic treatment in psychiatry and have enjoyed widespread application for the benefit of many. A number of theories have been advanced in efforts to account for therapeutic efficacy but none has been comprehensive. These theories can be distinguished by whether they posit a central therapeutic role for stimulation, inhibition, psychological effects, or mixed processes induced by treatment. After critically reviewing extant theories, we propose a model for the effects of the convulsive therapies: Convulsive therapy is essentially nonspecific; "nonphysiological" depolarizations are distinctly important for the restoration of aberrant intravesicular transmitter ratios with resultant therapeusis. We present this model as a working hypothesis that may contribute to the guidance of research in the mechanism of action of convulsive treatment and offer several testable hypotheses in this regard.

A study of factors associated with response to electroconvulsive therapy in patients with schizophrenic symptoms

Seventeen patients with schizophrenic symptoms were assessed before and after ECT to elicit possible factors predictive of outcome. The strongest associations with good outcome were shown by short duration of illness and paucity of pre-morbid schizoid personality traits; significant associations were also shown by short duration of current episode, paucity of paranoid pre-morbid personality traits, and the presence of perplexity. The diagnosis of schizoaffective disorder was not related to outcome. Questionnaires completed by 16 patients after ECT showed their attitudes to be generally favourable to the procedure.

Depression in schizophrenia: current guidelines to treatment

Depressive symptoms and syndromes in schizophrenia are common but heterogeneous with respect to etiology, presentation, course, and treatment. Based on a comprehensive differential diagnosis that identifies ten clinical subgroups, the authors review relevant treatment studies and offer current treatment guidelines. The clinical recommendations focus on addressing underlying problems such as medication side effects and substance abuse, attempting to identify and treat medication-responsive syndromes, and preventing suicide. The categories and treatments presented here are expected to evolve as researchers continue to elucidate clinically meaningful syndromes and to develop specific treatments. Nevertheless, current knowledge suggests that many schizophrenics with depression and depression-like symptoms can be treated effectively.

The effect of electroconvulsive therapy on CSF amine metabolites in schizophrenic patients

The effects of a series of six ECT treatments were observed on the CSF concentrations of HVA, MHPG, and 5-HIAA in 12 patients suffering from schizophrenia. Four patients were previously neuroleptic drug-free, and eight had received only oral neuroleptic drugs at the same dose for more than 4 weeks. A significant increase in the concentration of HVA was observed after the first ECT treatment but not after the final treatment. No significant changes were observed in the concentrations of MHPG and 5-HIAA. The patients improved clinically, and the results suggest that ECT has important effects on dopaminergic systems.

The efficacy of electroconvulsive therapy in the treatment of schizophrenia. A comparative study

The efficacy of ECT was investigated in a double-blind trial. Twenty-two patients with schizophrenia received trifluoperazine and were randomly allocated to receive eight real or eight simulated ECTs. In the first eight weeks, the group receiving real ECTs showed significantly more improvement as measured on the Brief Psychiatric Rating Scale. However, the groups showed no significant differences from the twelfth week onwards. The superiority of real ECT was not confirmed at the end of six months.