Combined use of clozapine and ECT: a review

Effectiveness of antipsychotic drug therapy for treating psychosis in people with epilepsy: A systematic review

Individuals with epilepsy are at risk of developing preictal, ictal, postictal and interictal psychoses. Antipsychotic drugs (APDs) are the main class of drugs used to treat psychosis and schizophrenia. The efficacy and safety of APDs as a treatment for epileptic psychosis is not well understood. This systematic review aimed to assess the effectiveness and adverse effects of APDs for treating psychosis in people with epilepsy. We adhered to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We searched MEDLINE, Embase, PsycInfo, and AMED (Allied and Complementary Medicine) from database inception to June 20, 2023. We contacted experts in the field and performed citation searches to identify additional records. Title, abstract, full-text review, and data analysis were conducted in duplicate, with conflicts resolved by discussion among authors. Given the considerable heterogeneity of study designs, meta-analysis was not deemed appropriate; instead, the results were tabulated in a narrative synthesis. The Joanna Briggs Institute Risk of Bias tool and GRADE (Grading of Recommendations Assessment, Development, and Evaluation) framework were used to assess study quality. We identified 13 studies with a total of 1180 participants. In the four case series included, the psychotic symptoms of 25 of 28 patients treated with APDs partially improved or fully resolved. Three of the four cohort studies reported an association between antipsychotic use and longer duration of psychotic episodes, two found similar results in both APD and non-APD groups, and two did not report control psychosis outcomes. When reported, seizure frequency was observed to remain unchanged or decrease following APD treatment. The evidence on the effectiveness of antipsychotics in the treatment of psychosis in epilepsy is inconclusive and may reflect confounding by indication. However, most studies suggest that antipsychotics were not associated with a marked worsening in seizure frequency. It remains unclear whether antipsychotics should be used in epilepsy, and well-controlled cohort studies and randomized controlled trials are necessary to draw definitive conclusions.

Clozapine in Treatment-Resistant Schizophrenia and Its Augmentation with Electroconvulsive Therapy in Ultra-Treatment-Resistant Schizophrenia

Clozapine is considered the gold standard for patients with treatment-resistant schizophrenia (TRS) who have previously tried other antipsychotics at adequate doses (two or more, with at least one being atypical). However, despite optimal treatment, a subgroup of TRS patients with what is known as ultra-treatment-resistant schizophrenia (UTRS) fails to respond to clozapine, which occurs in 40–70% of cases. The most common approach to manage UTRS involves augmenting clozapine with pharmacological or non-pharmacological interventions, with a growing body of evidence that supports the use of electroconvulsive therapy (ECT) as an augmenter. This prospective non-randomized 8-week study, which followed the TRIPP Working Group guidelines and is one of few that separate TRS from UTRS, aimed to evaluate the effectiveness of clozapine in TRS patients and the efficacy of ECT augmentation of clozapine in UTRS patients. Patients with TRS were assigned to receive clozapine alone (clozapine group), whereas UTRS patients received bilateral ECT in addition to their current medication regimen (ECT plus clozapine group). The severity of symptoms was evaluated using the Clinical Global Impression Scale (CGI) and Positive and Negative Syndrome Scale (PANSS) at baseline and at the end of the 8-week trial. Both treatment approaches resulted in improved CGI and PANSS scores. The results suggest that both clozapine and ECT are effective treatment options for patients with TRS and UTRS, respectively, and that adherence to guidelines should provide a better frame for future clinical studies.

Clozapine research from India: A systematic review

BACKGROUND

Although clozapine is much researched in western literature, a review on Indian research on clozapine published in 2010 reported limited data and need for further research in this area.

AIM

We aimed to conduct a systematic review of research on clozapine from India from 2010 to mid-2022 and also compare the same with research output before 2010.

METHODOLOGY

A systematic various search engines, i.e., PUBMED, Medknow, Hinari and Google Scholar was done using the key words clozapine and India. Published articles with clozapine in the title and having an author from India, published during 2010 to July 2022 were included.

RESULTS

Initial Internet and hand searches yielded 280 articles, out of which 126 articles were excluded due to various reasons and 154 articles, were included for the review. This included 84 case reports, 49 original articles, 11 review articles and 10 letters to the editor as comments. We found an increase in the number of publications during the period of 2010-2022 compared to 1997-2009 in all types of publications. Over the years a significant proportion of the articles focused on various side effects of clozapine, factors associated with response and non-response to clozapine and evaluation of outcomes other than efficacy/effectiveness. However, all the studies were limited to a single centre with no multicentric studies on clozapine.

CONCLUSION

Over the last 12 years or so, there is increase in the number of publications on clozapine. However, there is lack of multicentric studies.

Electrical stimulus combined with venlafaxine and mirtazapine improves brain Ca2+ activity, pre-pulse inhibition, and immobility time in a model of major depressive disorder in schizophrenia

BACKGROUND

The prevalence of major depressive disorder in patients with schizophrenia (SZ-MDD) has been reported to be about 32.6 %, but it varies considerably depending on the stage (early or chronic) and state (acute or post-psychotic) of schizophrenia. The exploration of ideal strategies for the treatment of major depressive disorder in the context of schizophrenia is urgently needed. Thus, the present study was conducted to investigate the treatment effects of clozapine, electrical stimulation (ECS; the mouse model equivalent of electroconvulsive therapy for humans), venlafaxine, and mirtazapine for SZ-MDD.

METHODS

A mouse model of SZ-MDD was established with MK801 administration and chronic unpredictable mild stress exposure. Clozapine and ECS, alone and with mirtazapine and/or venlafaxine, were used as treatment strategies. In-vivo two-photon imaging was performed to visualize Ca²⁺ neural activity in the prefrontal cortex (PFC). Mouse performance on behavioral assays was taken to reflect acute treatment effects.

RESULTS

ECS + venlafaxine + mirtazapine performed significantly better than other treatments in alleviating major depressive disorder, as reflected by PFC Ca²⁺ activity and behavioral assay performance. Clozapine + venlafaxine + mirtazapine did not have an ideal treatment effect. Brain Ca²⁺ activity alterations did not correlate with behavioral expression in any treatment group.

CONCLUSIONS

In this mouse model of SZ-MDD, ECS + venlafaxine + mirtazapine improved brain Ca2+ activity, pre-pulse inhibition, and immobility time. These findings provide useful information for the further exploration of treatment methods for patients with SZ-MDD, although the mechanisms underlying this comorbidity needed to be investigated further.

QEEG Biomarkers for ECT Treatment Response in Schizophrenia

Background: Electroconvulsive therapy (ECT) is a clinically effective treatment for schizophrenia (SZD). However, studies have shown that only about 50 to 80% of patients show response to ECT. To identify the most suitable patients for ECT, developing biomarkers predicting ECT response remains an important goal. This study aimed to explore the quantitative electroencephalography (QEEG) biomarkers to predict ECT efficacy. Methods: Thirty patients who met DSM-5 criteria for SZD and had been assigned to ECT were recruited. 32-lead Resting-EEG recordings were collected one hour before the initial ECT treatment. Positive and negative symptoms scale (PANSS) was assessed at baseline and after the eighth ECT session. EEG data were analyzed using mutual information. Results: In the brain network density threshold range of 0.05 to 0.2, the assortativity of the right temporal, right parietal, and right occipital cortex in the response group was significantly higher than that in the non-response group (p < .05) in the beta band. In the theta band, the left frontal, parietal, right occipital cortex, and central area assortativity were higher in the response group than in the non-response group (p < .05). Conclusions: QEEG might be a useful approach to identify the candidate biomarker for ECT in clinical practice.

Efficacy and safety of maintenance electroconvulsive therapy (M-ECT) in treatment-resistant schizophrenia: A case series

BACKGROUND

Treatment-resistant schizophrenia (TRS) is a substantial burden to patients, caregivers, and the treating team. There is a lack of robust evidence to support the efficacy of various pharmacological and non-pharmacological measures to augment clozapine in this population. When used in conjunction with clozapine or other combination antipsychotic regimens, maintenance electroconvulsive therapy (M-ECT) can be a potential therapeutic option in preventing symptom exacerbation in TRS. However, there is limited evidence supporting the role of M-ECT in TRS.

AIM

To evaluate the efficacy and safety of maintenance electroconvulsive therapy in patients with TRS.

METHODOLOGY

Sociodemographic details, illness characteristics, details of M-ECT procedure, adverse events, and course of the illness were evaluated using a retrospective chart review at a tertiary care psychiatry centre in south India. Scores on Clinical Global Impression-Severity (CGI-S), Social and Occupational Functioning Assessment Scale (SOFAS), and Hindi Mental Status Examination were compared before and after the course of M-ECT.

RESULTS

Seven male and three female patients received M-ECT in the last eight years (range of 22-172 sessions). There was a reduction in hospitalizations for acute exacerbation and significant improvement in the patient's overall functioning without significant adverse effects.

CONCLUSION

Maintenance ECT can be a safe and effective treatment option for achieving symptom control in the long-term management of refractory schizophrenia. Controlled trials are needed in this area for further evidence.

Structural and Functional MRI Brain Changes in Patients with Schizophrenia Following Electroconvulsive Therapy: A Systematic Review

BACKGROUND

Schizophrenia (SZ) is a severe psychiatric disorder typically characterized by multidimensional psychotic syndromes. Electroconvulsive therapy (ECT) is a treatment option for medication-resistant patients with SZ or treating acute symptoms. Although the efficacy of ECT has been demonstrated in clinical use, its therapeutic mechanisms in the brain remain elusive.

OBJECTIVE

This study aimed to summarize brain changes on structural magnetic resonance imaging (sMRI) and functional MRI (fMRI) after ECT.

METHODS

According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic review was carried out. The PubMed and Medline databases were systematically searched using the following medical subject headings (MeSH): (electroconvulsive therapy OR ECT) AND (schizophrenia) AND (MRI OR fMRI OR DTI OR DWI).

RESULTS

This review yielded 12 MRI studies, including 4 with sMRI, 5 with fMRI and 3 with multimodal MRI. Increases in volumes of the hippocampus and its adjacent regions (parahippocampal gyrus and amygdala), as well as the insula and frontotemporal regions, were noted after ECT. fMRI studies found ECT-induced changes in different brain regions/networks, including the hippocampus, amygdala, default model network, salience network and other regions/networks that are thought to highly correlate with the pathophysiologic characteristics of SZ. The results of the correlation between brain changes and symptom remissions are inconsistent.

CONCLUSION

Our review provides evidence supporting ECT-induced brain changes on sMRI and fMRI in SZ and explores the relationship between these changes and symptom remission.

Comparison of Acute Followed by Maintenance ECT vs Clozapine on Psychopathology and Regional Cerebral Blood Flow in Treatment-Resistant Schizophrenia: A Randomized Controlled Trial

BACKGROUND AND HYPOTHESIS

In treatment-resistant schizophrenia (TRS), Clozapine is only approved treatment with undesirable side-effects, warranting better alternatives. Our hypothesis is acute followed by maintenance Electroconvulsive Therapy (M-ECT) will be comparable in efficacy and safety to Clozapine in TRS.

STUDY DESIGN

In this open-label trial, 60 TRS patients were randomized equally to M-ECT (following an acute-course) or Clozapine. Positive and Negative Syndrome Scale (PANSS), Clinical Global Impression Schizophrenia Scale (CGI-SCH), Montreal Cognitive Assessment (MoCA), and Global assessment of functioning (GAF) were measured and compared within and between the groups at baseline, 6 weeks, 12 weeks, and 24 weeks. SPECT-CT brain was done at baseline and 24 weeks to compare the changes in regional cerebral perfusion between the groups and correlate with the changes in the outcome-measures.

STUDY RESULTS

The PANSS-T scores changes from baseline over the observation-points were significant in both M-ECT and clozapine groups (P < .001), with comparatively better reduction with M-ECT (P < .001). Similar trends were observed in PANSS subscales, CGI-SCH and GAF in both groups, with significantly better improvement with M-ECT over the study-period. After 24 weeks, there was significantly better perfusion with M-ECT in bilateral prefrontal and temporal cortices (P < .05). With M-ECT, a positive correlation was found between changes in PANSS-P scores and left-lateral Temporal cortical perfusion (r = .465, P = .017).

CONCLUSIONS

Acute followed by M-ECT was more effective than clozapine over 6 months in reducing the positive and negative symptoms, general psychopathology, illness-severity, and improving the global functionality in TRS [clinicaltrials.gov: NCT03807882].

The Impact of Electroconvulsive Therapy on Negative Symptoms in Schizophrenia and Their Association with Clinical Outcomes

OBJECTIVE

The treatment efficacy of electroconvulsive therapy (ECT) for negative symptoms amongst patients with schizophrenia remains unclear. In this study, we aim to examine the effects of ECT on negative symptoms in schizophrenia and their association with other clinical outcomes, including cognition and function.

METHODS

This is a retrospective data analysis of patients with schizophrenia/schizoaffective disorder treated with ECT at the Institute of Mental Health (IMH), Singapore, between January 2016 and December 2019. Clinical outcomes were assessed by the Brief Psychiatric Rating Scale (BPRS), the Montreal Cognitive Assessment (MoCA), and Global Assessment of Function (GAF). Changes in scores were compared with repeated measures analysis of variance. Sequential structural modelling was utilized to examine the pathway relationships between changes in negative symptoms, global functioning, and cognition functioning after ECT.

RESULTS

A total of 340 patients were analysed. Hence, 196 (57.6%), 53 (15.5%), and 91 (26.7%) showed improvements, no change, and deterioration in negative symptoms, respectively. ECT-induced improvement of negative symptoms was significantly associated with improvement of global functioning (direct effect correlation coefficient (r): -0.496; se: 0.152; p = 0.001) and cognition function (indirect effect r: -0.077; se: 0.037; p = 0.035). Moreover, having capacity to consent, more severe baseline negative symptoms, lithium prescription, and an indirect effect of voluntary admission status via consent capacity predicted ECT associated negative symptoms improvement.

CONCLUSION

ECT is generally associated with improvements of negative symptoms in people with schizophrenia, which correlate with improvements of overall function. Possible novel clinical predictors of negative symptom improvement have been identified and will require further research and validation.

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.

Clozapine resistant schizophrenia: Newer avenues of management

About 40%-70% of the patients with treatment-resistant schizophrenia have a poor response to adequate treatment with clozapine. The impact of clozapine-resistant schizophrenia (CRS) is even greater than that of treatment resistance in terms of severe and persistent symptoms, relapses and hospitalizations, poorer quality of life, and healthcare costs. Such serious consequences often compel clinicians to try different augmentation strategies to enhance the inadequate clozapine response in CRS. Unfortunately, a large body of evidence has shown that antipsychotics, antidepressants, mood stabilizers, electroconvulsive therapy, and cognitive-behavioural therapy are mostly ineffective in augmenting clozapine response. When beneficial effects of augmentation have been found, they are usually small and of doubtful clinical significance or based on low-quality evidence. Therefore, newer treatment approaches that go beyond the evidence are needed. The options proposed include developing a clinical consensus about the augmentation strategies that are most likely to be effective and using them sequentially in patients with CRS. Secondly, newer approaches such as augmentation with long-acting antipsychotic injections or multi-component psychosocial interventions could be considered. Lastly, perhaps the most effective way to deal with CRS would be to optimize clozapine treatment, which might prevent clozapine resistance from developing. Personalized dosing, adequate treatment durations, management of side effects and non-adherence, collaboration with patients and caregivers, and addressing clinician barriers to clozapine use are the principal ways of ensuring optimal clozapine treatment. At present, these three options could the best way to manage CRS until research provides more firm directions about the effective options for augmenting clozapine response.

Comparative study of effectiveness of augmentation with ECT in clozapine resistant schizophrenia (CRS) and non-clozapine resistant schizophrenia (Non-CRS)

BACKGROUND

There is limited evidence for different treatment strategies in patients with clozapine resistant schizophrenia (CRS).

AIM

To determine the effectiveness of ECT in patients with clozapine resistant schizophrenia and compare the same with a group of patients with non-clozapine resistant schizophrenia, receiving ECT.

RESULTS

Out of a total of 68 patients with schizophrenia, 27 (38.66%) of patients had CRS. With 6 ECTs, there was a significant reduction in PANSS positive, negative, general psychopathology, prosocial score and depression symptoms in the CRS (p < 0.001) and Non-CRS group (p < 0.001), but no statistically significant difference was seen between the 2 groups in terms of proportion of patients showing >40% response on PANSS total score. The reduction in PANSS score of >40% in CRS group was seen in 48.1% of patients in the positive symptoms subscale, in 25.9% of patients in negative symptoms subscale, in 46.7% of cases in the general psychopathology subscale, in 44.4% of the patients in Depression subscale, in 29.6% of the patients in the modified prosocialsubscaleand in 29.6% of the patients in total PANSS score.

CONCLUSION

ECT is an effective augmentation strategy for patients with CRS and it is as effective as when used in patients with non-CRS.

Antipsychotic Polypharmacy

Physicians who treat patients with schizophrenia frequently encounter complex clinical situations not fully addressed by published treatment guidelines. Some of these situations lead to antipsychotic polypharmacy, often prescribed when clinical and social obstacles prevent access to clozapine and patients have had suboptimal responses to nonclozapine monotherapy. We offer our perspective on the place of antipsychotic polypharmacy in the current treatment guidelines for patients with schizophrenia. We summarize data on the prevalence of antipsychotic polypharmacy and describe common clinical situations in which this practice is encountered, along with the pharmacological underpinnings of this practice. We briefly review evidence on common risks of antipsychotic polypharmacy and describe the limited evidence for the possible benefits of such practice. Moreover, we take a look at alternative antipsychotic augmentation strategies that address all domains of psychosis.

The Efficacy and Safety of Concomitant Psychotropic Medication and Electroconvulsive Therapy (ECT)

Electroconvulsive therapy (ECT) is an effective treatment for severe psychiatric disorders. Patients referred to ECT are often taking multiple medications, many of which can potentially affect the safety and efficacy of their course of ECT. This review evaluates the impact of a variety of psychotropic medications often used in conjunction with ECT and examines strategies to optimize their management. The review encompasses mood stabilizers, antidepressants, benzodiazepines, antiepileptics, antipsychotics, and other commonly used psychotropics.

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.

Acute electroconvulsive therapy in the elderly with schizophrenia and schizoaffective disorder: A case series

INTRODUCTION

There is a paucity of evidence regarding the use of electroconvulsive therapy (ECT) in the elderly with primary psychotic conditions, such as schizophrenia and schizoaffective disorder. This study examined the efficacy and safety of acute ECT treatment in late-life patients with primary psychotic conditions.

METHODS

A retrospective chart review was conducted on all patients aged 60 and above, who received ECT within a large metropolitan psychiatric facility in Australia between 2012 and 2018, and who were diagnosed with a primary psychotic condition. Information regarding demographic data, illness correlates, ECT treatment, treatment outcomes, and adverse effects was collected.

RESULTS

A total of 20 patients met inclusion into the study, 35% of whom were diagnosed with schizophrenia and 65% with schizoaffective disorder. The average age was 69 years. Patients had been trialed on an average of seven distinct antipsychotic agents prior to acute ECT treatment; 50% had been trialed on clozapine. ECT was associated with full (60%) or partial remission (35%) of psychotic illness in 95% (n = 19) of patients. No ECT-related fatalities were encountered. Adverse effects were experienced in 20% of patients, although none precluded the continuation of treatment.

DISCUSSION

This study found ECT to be a highly effective and safe treatment in the elderly with schizophrenia and schizoaffective disorder, who had not responded adequately to psychotropic medications.

Revisiting the role of electroconvulsive therapy in schizophrenia: Where are we now?

OBJECTIVE

The purpose of this opinion article is to review the recent evidence base in relation to the role of electroconvulsive therapy (ECT) in the management of patients with schizophrenia. Specifically, we explore the efficacy and safety of ECT. Furthermore, consideration is given to the profile of patients who benefit most from ECT, the role of maintenance ECT and what happens when ECT is not given.

CONCLUSION

Our brief review of the evidence suggests that clinical practice in developing countries has not kept up with the growing literature supporting ECT use in schizophrenia. As such, we advocate that ECT should not be a treatment of last resort. Rather, it should be considered more readily as an add-on therapy when there has been a poor response to antipsychotic medications or concerns exist about side effects. Further research is needed into the efficacy of maintenance ECT.

Acute electroconvulsive therapy in the elderly with schizophrenia and schizoaffective disorder: a literature review

OBJECTIVES

This study reviewed the evidence regarding the efficacy of acute electroconvulsive therapy for primary psychotic conditions in the elderly.

METHODS

A literature search was performed using the Medline, Embase and Cochrane databases.

RESULTS

Acute electroconvulsive therapy resulted in an improvement of psychotic symptoms in almost all elderly patients, a large proportion of whom had treatment-resistant conditions. No electroconvulsive therapy related fatalities or severe medical complications were encountered.

CONCLUSIONS

Acute electroconvulsive therapy may present a valuable treatment modality for elderly patients with primary psychotic conditions who do not respond adequately to antipsychotic medications.

ECT in schizophrenia: a review of the evidence

Electroconvulsive therapy (ECT) was initially used for the treatment of schizophrenia, but over the years with the advent of antipsychotics, its use in schizophrenia has been limited. Treatment guidelines vary in their recommendations for the use of ECT in schizophrenia. The usual indications of its use among patients with schizophrenia include treatment resistance, to augment pharmacotherapy, to manage catatonia, suicidal behaviour, severe agitation and clozapine-resistant schizophrenia. Available literature, including meta-analysis and systematic reviews, suggest that ECT is a safe and effective treatment in patients with schizophrenia. However, despite the available evidence, it is highly underutilised and is often used as one of the last resort among patients with schizophrenia. This review focuses on the indications of use of ECT in schizophrenia, studies evaluating its effectiveness, efficacy in certain special situations like first episode schizophrenia, adolescents, catatonia etc., predictors of response to ECT in schizophrenia and influence of various ECT-related parameters on efficacy/effectiveness among patients with schizophrenia. From the review, it can be concluded that ECT is not only is beneficial as an augmenting strategy in treatment-resistant schizophrenia but also can be used effectively in patients with schizophrenia in various other situations.

Combination of Electroconvulsive Therapy and Clozapine in Treatment-Resistant Schizophrenia

OBJECTIVE

This study aimed to investigate the effectiveness and tolerability of the combination of electroconvulsive therapy (ECT) in patients with clozapine-treated schizophrenia.

METHODS

Patients with clozapine-treated schizophrenia during five years of pre-determined period were recruited from Electronic Medical Record. Clinical effects of acute ECT on psychotic symptoms were investigated. We also tried to identify predictive variables requiring maintenance treatment of ECT.

RESULTS

Fourteen patients received ECT and clozapine and sixteen were treated with clozapine alone. In the ECT group, which could be refined as clozapine-resistance, PANSS total score was significantly reduced by 19.0±9.9 points, corresponding to a reduction rate of 18.5±8.3%. The clinical remission defined as 20% PANSS reduction criteria was achieved at 42.9%. The subscale factors were significantly reduced, among which the negative symptom was the least. There was no difference in demographic and clinical information between patients receiving and not receiving maintenance ECT, and not all patients seemed to need maintenance ECT if clozapine is continued.

CONCLUSION

Combination of ECT and clozapine in patients with clozapine-resistant schizophrenia resulted in a rapid and substantial reduction of psychotic symptoms. Further studies are needed to improve the effectiveness and tolerability of ECT.

Maintenance ECT in schizophrenia: A systematic review

Relapse after discontinuation of ECT is significant in patients with schizophrenia. The purpose of this systematic review was to examine use of M-ECT in schizophrenia to guide clinical decision making for relapse prevention in schizophrenia. We reviewed studies examining the role of continuation (C-ECT) and maintenance electroconvulsive therapy (M-ECT) in schizophrenia. Following PRISMA guidelines, we included randomized controlled trials, open label trials, retrospective chart reviews, case reports, and case series in this review. We evaluated adjunctive pharmacological regimens; ECT treatment parameters, including frequency, duration of continued treatment, electrode placement; clinical outcomes including cognitive side effects and relapse rates from included studies. Our findings suggest M-ECT could provide an effective form of relapse prevention in these patients and persistent cognitive side effects are minimal.

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.

Clozapine-resistant schizophrenia – non pharmacological augmentation methods

Clozapine is the drug of choice for drug-resistant schizophrenia, but despite its use, 30-40% patients fail to achieve satisfactory therapeutic effects. In such situations, augmentation attempts are made by both pharmacological and non-pharmacological methods. To date, most of the work has been devoted to pharmacological strategies, much less to augemantation of clozapine with electroconvulsive therapy (C+ECT), transcranial direct current stimulation (tDCS) or transcranial magnetic stimulation (TMS).

Aim: The aim of the work is to present biological, non-pharmacological augmentation treatment methods with clozapine.

Material and methods: A review of the literature on non-pharmacological augmentation treatment methods with clozapine was made. PubMed database was searched using key words: drug-resistant schizophrenia, clozapine, ECT, transcranial magnetic stimulation, transcranial electrical stimulation and time descriptors: 1980-2017.

Results: Most studies on the possibility of increasing the efficacy of clozapine was devoted to combination therapy with clozapine + electric treatments. They have shown improved efficacy when using these two methods simultaneously from 37.5 to 100%. The only randomized trial so far has also confirmed the effectiveness of this procedure. Despite the described side effects of tachycardia or prolonged seizures, most studies indicate the safety and efficacy of combined use of clozapine and electroconvulsive therapy. Transcranial magnetic stimulation also appears to be a safe method in patients treated with clozapine. However, further research is needed before ECT can be included in standard TRS treatment algorithms. The data for combining transcranial electrical stimulation with clozapine, come only from descriptions of cases and need to be confirmed in controlled studies.

Conclusions: The results of studies on the possibility of increasing the effectiveness of clozapine using biological non-pharmacological treatment methods indicate a potentially beneficial effect of this type of methods in breaking the super-resistance in schizophrenia. Combination of clozapine and ECT can be considered as the most recommended strategy among these treatment methods.

Electroconvulsive therapy-induced brain functional connectivity predicts therapeutic efficacy in patients with schizophrenia: a multivariate pattern recognition study

Previous studies suggested that electroconvulsive therapy can influence regional metabolism and dopamine signaling, thereby alleviating symptoms of schizophrenia. It remains unclear what patients may benefit more from the treatment. The present study sought to identify biomarkers that predict the electroconvulsive therapy response in individual patients. Thirty-four schizophrenia patients and 34 controls were included in this study. Patients were scanned prior to treatment and after 6 weeks of treatment with antipsychotics only (n = 16) or a combination of antipsychotics and electroconvulsive therapy (n = 13). Subject-specific intrinsic connectivity networks were computed for each subject using a group information-guided independent component analysis technique. Classifiers were built to distinguish patients from controls and quantify brain states based on intrinsic connectivity networks. A general linear model was built on the classification scores of first scan (referred to as baseline classification scores) to predict treatment response. Classifiers built on the default mode network, the temporal lobe network, the language network, the corticostriatal network, the frontal-parietal network, and the cerebellum achieved a cross-validated classification accuracy of 83.82%, with specificity of 91.18% and sensitivity of 76.47%. After the electroconvulsive therapy, psychosis symptoms of the patients were relieved and classification scores of the patients were decreased. Moreover, the baseline classification scores were predictive for the treatment outcome. Schizophrenia patients exhibited functional deviations in multiple intrinsic connectivity networks which were able to distinguish patients from healthy controls at an individual level. Patients with lower classification scores prior to treatment had better treatment outcome, indicating that the baseline classification scores before treatment is a good predictor for treatment outcome.

Effectiveness of Electroconvulsive Therapy Augmentation on Clozapine-Resistant Schizophrenia

OBJECTIVE

This retrospective case series study of the effectiveness of electroconvulsive therapy (ECT) augmentation on clozapine-resistant schizophrenia was conducted by EMR review.

METHODS

Clozapine-resistance was defined as persistent psychotic symptoms despite at least 12 weeks of clozapine administration with blood levels over 350 ng/mL in order to rule out pseudo-resistance. Seven in-patients who were taking clozapine and treated with ECT were selected. We analyzed the psychopathology and subscales changed by ECT.

RESULTS

The average number of ECT sessions was 13.4 (±4.6). Total Positive and Negative Syndrome Scale (PANSS) score was significantly reduced by 17.9 (±12.8) points (p=0.0384) on average, which represented a reduction of 25.5% (±14.3). 71.4% (5/7) of patients were identified as clinical remission, with at least a 20% reduction in PANSS score. PANSS reduction was associated with number of ECT sessions, stimulus level in the final session, and blood clozapine levels before ECT. However, the negative subscale on the PANSS were not reduced by ECT in any patient. We did not observe any persistent adverse cognitive effects.

CONCLUSION

This study supports that ECT augmentation on clozapine-resistant schizophrenia reveals clinically effective and safe. Further research should be done involving a larger number of patients to investigate the effectiveness of clozapine/ECT combination therapy.

Adverse Effects of Electroconvulsive Therapy

Electroconvulsive therapy (ECT) is an effective treatment commonly used for depression and other major psychiatric disorders. We discuss potential adverse effects (AEs) associated with ECT and strategies for their prevention and management. Common acute AEs include headache, nausea, myalgia, and confusion; these are self-limiting and are managed symptomatically. Serious but uncommon AEs include cardiovascular, pulmonary, and cerebrovascular events; these may be minimized with screening for risk factors and by physiologic monitoring. Although most cognitive AEs of ECT are short-lasting, troublesome retrograde amnesia may rarely persist. Modifications of and improvements in treatment techniques minimize cognitive and other AEs.

Prescription practices and attitude of psychiatrists towards clozapine: A survey of psychiatrists from India

AIM

To assess the attitude of psychiatrists towards clozapine and also to evaluate the prescription practices of psychiatrists for clozapine.

METHODOLOGY

An email survey was sent to 3381 psychiatrists from India, of whom 548 (16.2%) responded.

RESULTS

Mean number of years in clinical practice was 12.59 (SD-10.1) for participating psychiatrists. Majority of the participants rated their knowledge about clozapine to be good (61.5%)/very good (34.5%). The primary indication for use of clozapine for almost all the participants was treatment resistance and most of the psychiatrists initiated clozapine either in the dose of 25mg OD (44.3%) or 12.5mg OD (37%). Half (51.8%) of the psychiatrists preferred to use clozapine as BD dosing schedule, and median doses required to stabilize the patients ranged from 137.5 to 400mg/day. Once the clozapine dose had been stabilized, about half (51%) of the psychiatrists advised blood monitoring at monthly intervals. Almost all psychiatrists rated effectiveness of clozapine to be better than other antipsychotics. In terms of tolerability, 45.3% of the psychiatrists rated it as 'same as other antipsychotics' and 15.9% rated it as better than other antipsychotics. Most common patient and therapist related factors associated with reluctance to start clozapine were history of poor medication compliance and need for monitoring, respectively. Upon reviewing the prescription of other psychiatrists, participating psychiatrists reported that in about 28.46% of patients clozapine was not prescribed though indicated.

CONCLUSIONS

This survey suggests that clozapine is underused in India, although psychiatrists have adequate knowledge about the drug but many psychiatrists have negative attitude towards clozapine.