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

An Update on the Use of Neuromodulation Strategies in the Treatment of Schizophrenia

The field of neuromodulation has evolved tremendously and now includes a vast array of interventions utilizing different technologies that span electrical, magnetic, and ultrasound forms of stimulation. The evolution of interventions holds the promise of fewer adverse effects and a noninvasive approach, increasing the scale at which these interventions may be offered in hospital and community settings. While the majority of neuromodulation studies have focused on patients with mood disorders, predominantly depression, there is an unmet need for patients with schizophrenia, who are in dire need of novel therapeutic options. Advances in neuroimaging and approaches for examining individual variability and transdiagnostic symptoms may lead to more effective neuromodulation treatments in this patient population. This overview explores the modern landscape of invasive and noninvasive neuromodulation treatments for patients with schizophrenia. It begins with approaches that involve diffuse stimulation of the cortex and subcortex and then reviews more focal stimulation approaches at the cortical and subcortical levels. The authors also reflect on the relationship between our understanding of the neurobiology of schizophrenia and neuromodulation interventions.

EANM perspective on clinical PET and SPECT imaging in schizophrenia-spectrum disorders: a systematic review of longitudinal studies

PURPOSE

There is a need for biomarkers in psychiatry to improve diagnosis, prognosis and management, and with confirmed value in follow-up care. Radionuclide imaging, given its molecular imaging characteristics, is well-positioned for translation to the clinic. This systematic review lays the groundwork for integrating PET and SPECT imaging in the clinical management of schizophrenia-spectrum disorders.

METHODS

Systematic search of PubMed, Embase, Web of Science and Cochrane library databases was conducted from the earliest date available until February 2024. The focus was on longitudinal studies evaluating PET or SPECT imaging in individuals with a schizophrenia-spectrum or another psychotic disorders. Quality assessment was done using the Newcastle-Ottawa Scale (NOS), NIH scale for before-after studies and Cochrane Risk of Bias tool version 2 (Cochrane RoB2). Studies were further categorised into three groups: preclinical and diagnosis, predicting disease course or personalising treatment.

RESULTS

Fifty-six studies were included in the systematic review investigating in total 1329 patients over a median of 3 months. Over two-thirds used PET tracers, whereas the remaining studies employed SPECT tracers. The most frequently investigated system was dopaminergic transmission, followed by cerebral metabolism and blood flow. [18F]FDOPA demonstrated large effect size in predicting conversion of subjects at risk and treatment response. Additionally, treatment dosage could be optimised to reduce side effects using [123I]IBZM or [11C]raclopride.

CONCLUSION

Molecular imaging holds significant promise for real-life application in schizophrenia, with two particularly encouraging avenues being the prediction of conversion/response to antipsychotic medication and the improved management of antipsychotic dosage. Further longitudinal studies and clinical trials will be essential for validating both the clinical effectiveness and economic sustainability, as well as for exploring new applications.

Efficacy and safety of xanomeline-trospium chloride in schizophrenia: A systematic review and meta-analysis

INTRODUCTION

Schizophrenia is one of the psychiatric illnesses with a higher mortality rate. Xanomeline, an oral muscarinic receptor agonist, combined with Trospium, a pan-muscarinic receptor antagonist, represents a promising new treatment for schizophrenia that has been tested in clinical trials. Herein, we aimed to perform a meta-analysis assessing Xanomeline-Trospium Chloride's (XTC) safety and efficacy for treating schizophrenia.

MATERIALS AND METHODS

MEDLINE, EMBASE, and Cochrane databases were searched for randomized clinical trials testing XTC safety and efficacy in patients with schizophrenia on May 03, 2024. The research protocol was registered with the International Prospective Register of Systematic Reviews (CRD42024547487). Data were examined using the Mantel-Haenszel method and 95% CIs. Heterogeneity was assessed using I2 statistics. R, version 4.3.2, was used for statistical analysis.

RESULTS

3 RCTs and 674 patients were included, of whom 332 (49%) received XTC. The change from baseline in the Positive and Negative Syndrome Scale (PANSS) total score was significantly higher in the XTC arm (MD -13.17; 95% CI -20.16 to -6.18; P = 0.0002; I2 = 100%). Treatment with XTC resulted in improvements across all subscales of the PANSS. Additionally, XTC was associated with the occurrence of cholinergic adverse events, including nausea (18,52% vs. 3,79%; RR 4.37; 95% CI 2.43 to 7.84; P < 0.000001; I2 = 19%) but was not associated with akathisia (MD -0.00; 95% CI -0.13 to 0.13; P = 0.9; I2 = 0%) or body weight gain (MD -0.36; 95% CI -1.18 to 0.46; P = 0.38; I2 = 51%).

CONCLUSION

XTC is effective in improving schizophrenia symptoms. However, it is associated with some bothersome AEs that may undermine its tolerability and lead to increased discontinuation rates, despite its efficacy.

Molecular Positron Emission Tomography and Single-Photon Emission Computed Tomography Imaging for Understanding the Neurobiological Mechanisms of Electroconvulsive Therapy: A Scoping Review

ABSTRACT

Electroconvulsive therapy (ECT) effectively treats severe psychiatric disorders such as depression, mania, catatonia, and schizophrenia. Although its exact mechanism remains unclear, ECT is thought to induce neurochemical and neuroendocrine changes. Positron emission tomography (PET) and single-photon emission computed tomography (SPECT) have provided vital insights into ECT's neurobiological effects. This scoping review investigates the role of molecular imaging in understanding these effects. A systematic search across PubMed, EMBASE, Web of Science, Cochrane, and Scopus databases yielded 857 unique records, from which 45 peer-reviewed articles in English with longitudinal PET or SPECT measures in ECT patients were included. The review identifies 2 main research directions: ECT's impact on brain activity and neurotransmitters. Initial research assessed regional cerebral blood flow and regional glucose metabolism during ictal (during ECT), postictal (within 24 hours), short-term (within a week), and long-term (beyond a week) follow-up as markers of brain activity. Initial findings showed an anterior-posterior regional cerebral blood flow gradient during the ictal phase, with subsequent normalization of hypoperfusion in frontal and parietal regions, and persistent long-term effects. Later, research shifted to the monoamine hypothesis of depression, examining ECT's impact on serotonin and dopamine systems via PET imaging. Results on receptor availability post-ECT were mixed, showing both reductions and no significant changes, indicating variable effects. This scoping review further highlights the need to explore new targets, tailor methodologies for patient populations, and foster multicenter studies. Although SPECT has been valuable, advances in PET imaging now make it preferable, offering unparalleled insights into ECT's molecular and neurobiological mechanisms.

Analysis of clinical studies on clozapine from 2012-2022

Clozapine has been considered the "gold standard" in the treatment of schizophrenia for many years. Clozapine has a superior effect, particularly in the treatment of negative symptoms and suicidal behaviour. However, due to its numerous adverse reactions, clozapine is mainly used for treatment-resistant schizophrenia. The aim of this paper is to analyze the results of clinical studies on clozapine from 2012-2022. PubMed was used as the database. Sixty-four studies were included and categorised by topic. The pharmacokinetic properties of clozapine tablets and a clozapine suspension solution did not differ markedly. Clozapine was superior to olanzapine and risperidone in reducing aggression and depression. A long-term study showed that metabolic parameters changed comparably with olanzapine and clozapine after 8 years. Risperidone and ziprasidone can be used as an alternative to clozapine. Scopolamine, atropine drops, and metoclopramide are effective in the treatment of clozapine-induced hypersalivation. Eight drugs, including liraglutide, exenatide, metformin, and orlistat, are potentially effective in the treatment of clozapine-induced weight gain. Ziprasidone, haloperidol, and aripiprazole showed a positive effect on symptoms when added to clozapine. No investigated drug was superior to clozapine for the treatment of schizophrenia. Ziprasidone and risperidone can also be used well for the treatment of schizophrenia. In the treatment of clozapine-induced hypersalivation and weight gain, some drugs proved to be effective.

Adjunctive clozapine with bright light mitigates cognitive deficits by synaptic plasticity and neurogenesis in sub-chronic MK-801 treated mice

Schizophrenia impacts about 1 % of the global population, with clozapine (CLZ) being a critical treatment for refractory cases despite its limitations in effectiveness and adverse effects. Therefore, the search for more effective treatments remains urgent. Light treatment (LT) recognized for enhancing cognition and mood, presents a promising complementary approach. This study investigated the effects of CLZ and LT on cognitive impairments in a sub-chronic MK-801 induced schizophrenia mouse model. Results showed that both CLZ and CLZ + LT treatment elevate cognitive performance of sub-chronic MK-801 treated mice in serial behavioral tests over two months. Histological analysis revealed increased dendritic spine density and branching, and synaptic repair in the hippocampus with CLZ and CLZ + LT interventions. Furthermore, both treatments increased brain-derived neurotrophic factor (BDNF) expression in the hippocampus, likely contributing to cognitive amelioration in MK-801 treated mice. Additionally, BrdU labeling revealed that CLZ + LT further enhances neurogenesis in the dentate gyrus (DG) and lateral ventricle (LV) of sub-chronic MK-801 treated mice. These findings may have implications for the development of noninvasive and adjunctive treatment strategies aimed at alleviating cognitive impairments and improving functional outcomes in individuals with schizophrenia.

Clinical Outcomes of Continuation and Maintenance Electroconvulsive Therapy

Importance

Large-scale evidence for the efficacy of continuation and maintenance electroconvulsive therapy (c/mECT) is lacking.

Objective

To provide an exhaustive and naturalistic insight into the real-world outcomes and the cost-effectiveness of c/mECT in a large dataset.

Design, Setting, and Participants

This cohort study included all patients in the Danish National Patient Registry who initiated treatment with ECT from 2003 through 2022. The data were analyzed from October 2023 to February 2024.

Exposures

ECT. An algorithm to identify c/mECTs in the dataset was developed: (>3 treatments with ≥7 and <90 days between adjacent treatments, occurring within a time frame of 180 days [cECT] or more [mECT] after an acute [aECT] series).

Main Outcomes and Measures

The association of c/mECT with subsequent 6- to 12-month risk of hospitalization or suicidal behavior using Cox proportional hazard regression with multiple adjustments and aECT only as a reference, propensity score matching, and self-controlled case series analysis using a Poisson regression model. A cost-effectiveness analysis based on hospitalization and ECT expenses was made.

Results

A total of 19 944 individuals were treated with ECT (12 157 women [61%], 7787 men [39%]; median [IQR] age, 55 [41-70] years). Of these, 1533 individuals (7.7%) received c/mECT at any time point (1017 [5.1%] cECT only and 516 [2.6%] mECT). Compared with patients receiving aECT only, c/mECT patients more frequently experienced schizophrenia (odds ratio [OR], 2.14; 95% CI, 1.86-2.46) and schizoaffective disorder (OR, 2.42; 95% CI, 1.90-3.09) and less frequently unipolar depression (OR, 0.56; 95% CI, 0.51-0.62). In all models, c/mECT was associated with a lower rate of hospitalization after finishing aECT (eg, 6-month adjusted hazard ratio, 0.68; 95% CI, 0.60-0.78 [Cox regression]; 6-month incidence rate ratio, 0.51; 95% CI, 0.41-0.62 [Poisson regression]). There was no significant difference in the risk of suicidal behavior. Compared with the periods before the end of aECT, c/mECT was associated with a substantial reduction in total treatment costs.

Conclusions and Relevance

In a nationwide and naturalistic setting, c/mECT after aECT was infrequently used but associated with a lower risk of readmission than aECT alone. The totality of the evidence indicates that c/mECT should be considered more often to prevent relapse after successful aECT in patients whose condition does not respond sufficiently to other interventions.

A lifetime of mental health treatments for people with schizophrenia: update and narrative review

PURPOSE OF REVIEW

To provide a summary of the most up-to-date thoughts about treatment for schizophrenia at different stages of illness.

RECENT FINDINGS

The use of Coordinated Specialty Care clinics has arisen as the standard for early on in the treatment of psychosis, providing the notion that recovery is possible. New medications that do not depend on postsynaptic dopamine receptor blockade are soon becoming available.

SUMMARY

A focus should be made by clinicians to personalize treatment plans for each patient who has the possibility of being diagnosed with a primary psychosis and the plan should be to predict outcomes based on biological markers that include genetic vulnerability, early psychosocial combined with pharmacological treatments as needed and then a plan to determine or maintain treatments going forward into the future. It is important to individualize treatment by stage of illness, as well as characteristics of the individual patient. Research is ongoing to advance knowledge for interventions at each stage from the premorbid period through to chronicity.

Examining the clinical effectiveness of continuation and maintenance electroconvulsive therapy in schizophrenia

OBJECTIVE

There are few studies that examine the effectiveness of Continuation/Maintenance Electroconvulsive Therapy (C/M-ECT) in schizophrenia, despite the documented effectiveness of acute ECT treatment. We aimed to investigate the clinical effectiveness of C/M-ECT for in-patients with Schizophrenia in a naturalistic setting. We examined the medical records of 46 in-patients who were diagnosed with Schizophrenia and had received C/M-ECT belonging to non-acute extended care service in a public psychiatry hospital in Sydney, Australia. The focus of analysis was on 138 treatment cycles (71 acute only cycles and 67 acute-continuation/maintenance cycles) across 45 subjects. A linear mixed effects model was used to describe the change in clinical global impression-severity (CGI-S) over time 4 time points viz., pre-post acute and pre-post continuation/maintenance ECT.

RESULTS

Acute-only cycles and acute-continuation/maintenance cycles had identical pre- (M = 5, C.I. = 4-6), post-cycle CGI-S scores, and identical CGI-S difference scores (M = 0, C.I. = -1 - 1). Broadly in each continuation/maintenance cycle, we observed an initial sharp decrease in CGI-S scores followed by a logarithmic increase in scores over time, with satisfactory CGI-S score maintenance observed for approximately 6 months. Bitemporal ECT influenced CGI-S across maintenance ECT (p < 0.05) indicating smaller declines in CGI-S scores over time.

CONCLUSION

In schizophrenia, C/M ECT preserves effects on illness severity for at least upto 6 months following an acute course of ECT. Bitemporal ECT vis a vis other electrode positions differentiated clinical severity over time.

An international research agenda for clozapine-resistant schizophrenia

Treatment-resistant symptoms occur in about a third of patients with schizophrenia and are associated with a substantial reduction in their quality of life. The development of new treatment options for clozapine-resistant schizophrenia constitutes a crucial, unmet need in psychiatry. Additionally, an overview of past and possible future research avenues to optimise the early detection, diagnosis, and management of clozapine-resistant schizophrenia is unavailable. In this Health Policy, we discuss the ongoing challenges associated with clozapine-resistant schizophrenia faced by patients and health-care providers worldwide to improve the understanding of this condition. We then revisit several clozapine guidelines, the diagnostic tests and treatment options for clozapine-resistant schizophrenia, and currently applied research approaches in clozapine-resistant schizophrenia. We also suggest methodologies and targets for future research, divided into innovative nosology-oriented field trials (eg, examining dimensional symptom staging), translational approaches (eg, genetics), epidemiological research (eg, real-world studies), and interventional studies (eg, non-traditional trial designs incorporating lived experiences and caregivers' perspectives). Finally, we note that low-income and middle-income countries are under-represented in studies on clozapine-resistant schizophrenia and propose an agenda to guide multinational research on the cause and treatment of clozapine-resistant schizophrenia. We hope that this research agenda will empower better global representation of patients living with clozapine-resistant schizophrenia and ultimately improve their functional outcomes and quality of life.

The clinical profile and outcome of patients receiving continuation electroconvulsive therapy (C-ECT): A retrospective study

BACKGROUND

There is a lack of data on the use of continuation electroconvulsive therapy (C-ECT) from India.

OBJECTIVES

This study aimed to evaluate the clinical profile and outcome of patients receiving C-ECT.

MATERIALS AND METHODS

The ECT register was used to identify patients receiving C-ECT (ECT after completion of an acute course, to maintain remission or prevent relapse) from 2011 to July 2022. Socio-demographic, clinical, and treatment outcome details were extracted from their treatment records.

RESULTS

A total of 72 C-ECT courses were identified that were used in 60 patients. Out of all the patients receiving ECT, only 3.25% of patients receive C-ECT. The majority of the patients were male (60%). The mean age of the patients at the time of starting ECT was around 39 years. The most common diagnosis was schizophrenia (73.3%), followed by recurrent depressive disorder (21.6%). The most common indication was persistent psychotic symptoms poorly responding to multiple antipsychotic trials of 3.09 (SD: 1.39), including clozapine. These patients received a mean of 22.58 (SD: 8.05; range: 10 to 46) ECTs, with 10.0 (SD: 4.83) ECTs for the management of the acute phase of illness and 12.57 (SD: 6.20) ECTs as part of continuation treatment. The majority (61.1%) of the patients received four (once weekly) C-ECTs in the first month, followed by three more in the next month. However, 16 patients received weekly ECTs during the second month too, as symptoms worsened with the lowering of frequencies. Twelve patients received more than one C-ECT course. The majority of the patients maintained the improvement gained during the acute phase or showed further improvement with C-ECT along with ongoing pharmacotherapy as rated on appropriate scales. The Clinical Global Impressions-Severity (CGI-S) difference before and after C-ECTs was 2.94 (SD: 0.88).

CONCLUSIONS

C-ECT is considered in only in a small proportion of patients. However, when used, it is effective in maintaining the benefits gained during the acute course of ECT and preventing relapse.

Altered Patterns of Brain Glucose Metabolism Involve More Extensive and Discrete Cortical Areas in Treatment-resistant Schizophrenia Patients Compared to Responder Patients and Controls: Results From a Head-to-Head 2-[18F]-FDG-PET Study

BACKGROUND AND HYPOTHESIS

Treatment resistant schizophrenia (TRS) affects almost 30% of patients with schizophrenia and has been considered a different phenotype of the disease. In vivo characterization of brain metabolic patterns associated with treatment response could contribute to elucidate the neurobiological underpinnings of TRS. Here, we used 2-[18F]-fluorodeoxyglucose (FDG) positron emission tomography (PET) to provide the first head-to-head comparative analysis of cerebral glucose metabolism in TRS patients compared to schizophrenia responder patients (nTRS), and controls. Additionally, we investigated, for the first time, the differences between clozapine responders (Clz-R) and non-responders (Clz-nR).

STUDY DESIGN

53 participants underwent FDG-PET studies (41 patients and 12 controls). Response to conventional antipsychotics and to clozapine was evaluated using a standardized prospective procedure based on PANSS score changes. Maps of relative brain glucose metabolism were processed for voxel-based analysis using Statistical Parametric Mapping software.

STUDY RESULTS

Restricted areas of significant bilateral relative hypometabolism in the superior frontal gyrus characterized TRS compared to nTRS. Moreover, reduced parietal and frontal metabolism was associated with high PANSS disorganization factor scores in TRS (P < .001 voxel level uncorrected, P < .05 cluster level FWE-corrected). Only TRS compared to controls showed significant bilateral prefrontal relative hypometabolism, more extensive in CLZ-nR than in CLZ-R (P < .05 voxel level FWE-corrected). Relative significant hypermetabolism was observed in the temporo-occipital regions in TRS compared to nTRS and controls.

CONCLUSIONS

These data indicate that, in TRS patients, altered metabolism involved discrete brain regions not found affected in nTRS, possibly indicating a more severe disrupted functional brain network associated with disorganization symptoms.

The effect of continuation and maintenance electroconvulsive therapy on cognition: A systematic review of the literature and meta-analysis

BACKGROUND

Electroconvulsive therapy (ECT) is an effective treatment for depression, mania, and refractory schizophrenia. Its tolerability profile is established for acute treatment, but less is known regarding the effects of longer treatment courses, particularly on cognitive performance.

OBJECTIVES

To assess the effect of the long-term ECT on cognition.

METHODS

We searched CINAHL, EMBASE, PsychInfo and Pubmed, for the period between January 1, 2010, and June 30, 2022, in English or French, for randomized controlled trials, prospective or retrospective studies of ECT continued for at least 2 months for the treatment of mood or schizophrenic disorders and which measured cognition before and at the end of treatment. Non-peer reviewed records were excluded. The Cochrane Risk of Bias tool was used to assess study quality. Classical meta-analyses, with heterogeneity statistics (tau², I²) were complemented with three level-meta-analysis and Bayesian Meta-analyses.

RESULTS

Nine studies were included in the narrative and quantitative review. Controlled comparison at 6 months (k = 6, n = 334) and at 12 months (k = 3, n = 56), within-subject comparisons at 6 (k = 6, n = 218) and 12 months (k = 4, n = 147) showed no detrimental effect of maintenance or continuation ECT on cognition, with little to no heterogeneity. Bayesian analysis further confirmed that data better supported the no effects hypothesis.

LIMITATIONS

Insufficient data resulted in imprecision in estimates.

CONCLUSIONS

Continuation and maintenance ECT do not appear detrimental for cognitive performance. However, the low number of studies limit the interpretation of the results.

The effects of Baduanjin exercise vs. brisk walking on physical fitness and cognition in middle-aged patients with schizophrenia: A randomized controlled trial

OBJECTIVE

Patients with schizophrenia have deficits in physical and cognitive function that may become salient in their middle ages. These deficits need active intervention to prevent functional decline. Baduanjin and brisk walking show promise as interventions in patients with schizophrenia. This study investigated the effects of Baduanjin exercise vs. brisk walking in middle-aged patients with schizophrenia.

METHODS

In this single-blind, 2-arm, parallel, randomized controlled trial, 48 participants aged older than 40 years were enrolled and assigned to the intervention group (Baduanjin) or the control group (brisk walking). The training of both groups took place twice a week, 60 min per session, for 12 weeks. The participants were evaluated with physical, cognitive, and functional outcomes at baseline, postintervention, and 4 weeks after the intervention.

RESULTS

The results of the study demonstrated significant time effects in walking distance (p = 0.035, η² = 0.094) and lower extremity strength (p = 0.006, η² = 0.152). Post-hoc analysis revealed both groups had significant improvement in changes from baseline to the postintervention assessment (ps < 0.05) and follow-up (ps < 0.05). The results demonstrated a significant group-by-time interaction in change scores of global cognition (F = 7.01, p = 0.011, η² = 0.133). Post-hoc analysis revealed a significant improvement in the Baduanjin group from baseline to postintervention (p = 0.021), but the improvements were not maintained at the follow-up assessment (p = 0.070). The results also demonstrated significant group effects in balance function (p < 0.001, η² = 0.283), motor dual-task performance (p = 0.026, η² = 0.103), and cognitive dual-task performance (p < 0.001, η² = 0.307). Post-hoc analysis revealed that the Baduanjin group improved more than the brisk walking group in the above outcomes (ps < 0.05).

CONCLUSION

This study demonstrated the differential effects of Baduanjin exercise and brisk walking in middle-aged patients with schizophrenia. Baduanjin might be a beneficial regimen for improving physical and cognitive function in this population. Further research with a larger sample is warranted.

CLINICAL TRIAL REGISTRATION

[ClinicalTrials.gov], identifier [202000817B0C602].

Underuse of recommended treatments among people living with treatment-resistant psychosis

BACKGROUND

International guidelines recommend that individuals with treatment-resistant psychosis must be treated with clozapine. ECT has also been reported to improve symptom profiles. Identification of clozapine and/or ECT use in real-world practice enables understanding of the extent to which this evidence-base is implemented.

SETTING

Statewide public health tertiary referral service, the Tertiary Referral Service for Psychosis (TRSP), NSW, Australia.

OBJECTIVES

To (i) describe clinical characteristics of individuals with treatment-resistant psychosis and to detail the proportion who had received a trial of clozapine or ECT at any point during their illness course; (ii) describe the characteristics of the treatment trials in both those currently on clozapine and those previously on clozapine; (iii) document reasons in relevant individuals why clozapine had never been used.

METHODS

All TRSP clients who met the criteria for treatment resistance (TR) were included. A detailed casenote review was conducted to examine whether clozapine and/or ECT had ever been prescribed. Characteristics of clozapine and ECT trials were documented. Tertiary service treatment recommendations are described.

FINDINGS

Thirty-six of 48 individuals had TR. They had marked clinical and functional impairment. A minority were currently receiving clozapine (n = 14/36). Most had received a clozapine trial at some point (n = 32/36). Most experienced persistent clinical symptoms while on clozapine (n = 29/32). Clozapine plasma levels were very rarely reported (4/32). Augmentation and antipsychotic polypharmacy were common among those currently on clozapine. The median clozapine trial duration was 4.0 (IQR: 3.0-20.3) months in individuals previously prescribed clozapine. Reasons for clozapine discontinuation included intolerable side effects (n = 10/18) and poor adherence (n = 7/18). One-quarter of TR individuals had trialed ECT (n = 9/36). Tertiary service recommendations included routine plasma monitoring to optimize dose among people currently on clozapine; clozapine retrial in those previously treated; and clozapine initiation for those who had never received clozapine. ECT was recommended to augment clozapine and as an alternative where clozapine trial/retrial was not feasible.

CONCLUSION

Among people with TR referred to a tertiary service, clozapine and ECT were underutilized. Clozapine trials are typically terminated without an adequate trial. Strategies to optimize the use of clozapine therapy and ECT in clinical settings are needed to increase the therapeutic effectiveness of evidence-based therapies for treatment-resistant psychosis.