Factors influencing treatment frequency of continuation ECT in schizophrenia

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.

Electroconvulsive therapy for negative symptoms in schizophrenia: a literature review from 2000 to 2021

Negative symptoms in schizophrenia remain a clinical challenge with small effect sizes and evidence for pharmacological or psychotherapeutic treatment approaches. Studies suggest that electroconvulsive therapy (ECT) holds some promise as a treatment option of often persistent negative symptoms with clinically meaningful effects. This review summarizes the existing evidence on the efficacy of ECT on negative symptoms in patients with schizophrenia. Thirty-five publications were included in this literature review comprising 21 studies, two meta-analyses, eight reviews and four case reports. Conclusions should be interpreted cautiously, given the small number and methodological shortcomings of the included publications with a variation of study designs and missing standardized protocols. Implications for future research and practice are critically discussed. Recommendations are given to provide more evidence that will meet the clinical challenge of reducing the negative symptoms in schizophrenia. Study designs that focus explicitly on negative symptoms and assess patients over longer follow up periods could be helpful. Future research should include control groups, and possibly establish international multicentered studies to get a sufficient study population. Findings suggest that patients with schizophrenia resistant to pharmacological treatment might benefit from ECT. A risk and benefit assessment speaks in favour of the ECT treatment. Future practice of ECT should include a combination treatment with antipsychotics. Whereas the use of anaesthetics and electrode placement does not seem to play a role, the recommendation regarding frequency of ECT treatments is currently three times a week, For the assessment of negative symptoms the assessment tool should be chosen carefully.

ECT augmentation of antipsychotics in severely ill schizophrenia: a naturalistic, observational study

OBJECTIVES

There is positive evidence to support the role of electroconvulsive therapy (ECT) in the treatment of schizophrenia; however, it is unclear to what extent this growing evidence reflects the actual situation in clinical practice. The aim of this study was to explore the efficacy of ECT augmentation to antipsychotics in individuals with schizophrenia in a naturalistic-observational environment.

METHODS

Eighty-one patients diagnosed with schizophrenia, hospitalised due to acute psychotic exacerbation were included in the study. We compared changes in Positive and Negative Symptom Rating Scale (PANSS) scores between patients treated only with APs and those in the ECT augmentation group.

RESULTS

A statistically significant decrease in symptom severity was observed in all PANSS subscales in both groups. In the ECT group, 95% of the patients (n = 39) responded to treatment compared to 75% of the non-ECT group (n = 30) (χ²=6.496, df = 1, p = 0.011). We found that combining ECT with AP significantly increased treatment response, which was defined as at least 25% PANSS symptom reduction, in patients with acute exacerbation of schizophrenia, compared to AP alone.

CONCLUSIONS

Augmentation of ECT seems to increase responsiveness during acute treatment of severely ill schizophrenia patients. The mean percentage reduction in PANSS scores by 25% following antipsychotic treatment can help identify patients that will benefit from ECT after psychotic relapse in future. Key points There is positive evidence to support the role of ECT in the treatment of schizophrenia; however, it remains unclear to what extent this growing evidence reflects the actual situation in clinical practice. Augmentation of ECT seems to increase responsiveness during acute treatment of severely ill schizophrenia patients. The addition of ECT to antipsychotic treatment may only be beneficial in patients with antipsychotic responses below 50%. The mean percentage reduction in PANSS scores by 25% following antipsychotic treatment can help identify patients that will benefit from ECT after psychotic relapses in the future.

Clinical Effectiveness of Maintenance Electroconvulsive Therapy in Patients with Schizophrenia: A Retrospective Cohort Study

OBJECTIVE

This study aimed to assess the clinical effectiveness and cognitive effects of maintenance electroconvulsive therapy (mECT) in patients with schizophrenia or schizoaffective disorder and explore factors associated with both outcomes.

METHODS

In this retrospective cohort study, we examined clinical records of 47 patients with a Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) diagnosis of schizophrenia or schizoaffective disorder treated with mECT at an academic mental health hospital between April 2010 and July 2016. Sixty-two mECT courses were reviewed. We assessed clinical effectiveness and cognitive effects as well as factors associated with response to treatment, including psychiatric diagnosis, concomitant pharmacological treatment, and previous treatment response.

RESULTS

Maintenance electroconvulsive therapy was able to maintain clinical response in 48 (77%) treatment courses. Significant cognitive adverse effects were reported in 7 (11%) of the courses. Use of antipsychotic, antidepressant or benzodiazepine medications, psychiatric disorder, and sex were not associated with response.

CONCLUSION

This study shows meaningful clinical effectiveness and good tolerability of mECT in patients with resistant schizophrenia over extended periods.

Continuation Electroconvulsive Therapy for Patients With Clozapine-Resistant Schizophrenia: A Pilot Study

OBJECTIVES

The risk of relapse after a successful acute course of treatment is a clinical challenge in electroconvulsive therapy (ECT) practice, particularly in patients with a history of marked resistance to previous treatments. Research suggests that a gradual decrease of ECT or its long-term continuation might be the best strategy. Notwithstanding, current studies do not address the role of continuation ECT in the truly refractory cases, that is, the clozapine-resistant patients. Our group published a randomized controlled trial of ECT augmentation of clozapine in clozapine-resistant patients with schizophrenia, where the augmentation was vastly superior in efficacy for the acute treatment. The aim of the current study is to evaluate the efficacy of continuation ECT for patients who showed response to the combination of acute ECT and clozapine for treatment-resistant schizophrenia.

METHODS

Continuation ECT was offered to all patients who completed the acute study and who met response criterion. We followed a tapered schedule of 4 weekly ECT sessions, followed by 4 ECT sessions every 2 weeks and 2 monthly ECT sessions for a total of 10 sessions.

RESULTS

Patients sustained the gains achieved with the acute course of ECT, and no individual patient presented with clinically relevant worsening of symptoms. Moreover, the long-term use of ECT was not associated with added adverse effects.

CONCLUSIONS

This is an open pilot study with a small sample size, and results should be interpreted accordingly, but this report offers a relevant starting point for much needed future studies.

Commentary on Braga et al: The Potential of Large Simple Trials to Determine the Real-World Effectiveness of Combined Electroconvulsive Therapy and Antipsychotics in Treating Patients With Treatment-Resistant Schizophrenia

This commentary reflects upon the study of Braga et al of open-label continuation electroconvulsive therapy (ECT) plus clozapine in treatment-resistant schizophrenia (TRS), as reported in this issue of The Journal of ECT. The evidence base for ECT in TRS is scant, and the study of Braga et al is a step forward. However, their report raises other important questions including (1) what is the proper frequency of continuation ECT in TRS, and (2) should TRS patients, even TRS patients who have failed clozapine, receive acute ECT + clozapine, or is ECT + conventional antipsychotics sufficient? In this commentary, we examine these questions and outline a future research strategy for TRS that includes large simple trials.

Analysis of mineral apposition rates during alveolar bone regeneration over three weeks following transfer of BMP-2/7 gene via in vivo electroporation

Alveolar bone is not spontaneously regenerated following trauma or periodontitis. We previously proposed an animal model for new alveolar bone regeneration therapy based on the non-viral BMP-2/7 gene expression vector and in vivo electroporation, which induced the formation of new alveolar bone over the course of a week. Here, we analysed alveolar bone during a period of three weeks following gene transfer to periodontal tissue. Non-viral plasmid vector pCAGGS-BMP-2/7 or pCAGGS control was injected into palatal periodontal tissue of the first molar of the rat maxilla and immediately electroporated with 32 pulses of 50 V for 50 msec. Over the following three weeks, rats were double bone-stained by calcein and tetracycline every three days and mineral apposition rates (MAR) were measured. Double bonestaining revealed that MAR of alveolar bone was at similar level three days before BMP-2/7 gene transfer as three days after gene transfer. However, from 3 to 6 days, 6 to 9 days, 9 to 12 days, 12 to 15 days, 15 to 18 days, and 18 to 20 days after, MARs were significantly higher than prior to gene transfer. Our proposed gene therapy for alveolar bone regeneration combining nonviral BMP-2/7 gene expression vector and in vivo electroporation could increase alveolar bone regeneration potential in the targeted area for up to three weeks.

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.

The Effects of Electroconvulsive Therapy Augmentation of Antipsychotic Treatment on Cognitive Functions in Patients With Treatment-Resistant Schizophrenia

OBJECTIVES

Treatment-resistant schizophrenia (TRS) continues to be a challenge in modern psychiatry. Most of these patients have severe neurocognitive deficits. Electroconvulsive therapy (ECT) has proved effective and safe in the treatment of TRS, but because of potential neurocognitive adverse effects, it is associated with many controversies. The aim of this prospective, open study was to evaluate the effects of ECT augmentation of antipsychotics on cognitive functions in patients with TRS.

METHODS

Overall, 31 inpatients with TRS were included, 16 men, with an average (SD) age of 34.1 (11.187) years. The evaluation of clinical symptoms and global impression, as well as verbal memory, visual memory, working memory, psychomotor speed, verbal fluency, and executive functioning, was conducted before and after the completion of ECT treatment.

RESULTS

We ran a series of paired-samples t tests, and the Bonferroni adjustment for multiple comparisons reduced the significance level to P = 0.004. The neurocognitive domains that demonstrated statistically significant improvement were immediate and delayed verbal memory, and executive functioning, whereas statistical trend was observed for visual memory and psychomotor speed. None of the neurocognitive functions exhibited significant deterioration after the ECT treatment. Electroconvulsive therapy was effective in reducing general symptoms of schizophrenia, resulting in more than 30% decrease in the overall symptom severity measured by the Positive and Negative Syndrome Scale.

CONCLUSIONS

Notwithstanding some limitations of this study, the combination of ECT and antipsychotics has improved several neurocognitive domains, without evidence of worsening of any cognitive functions.

Patients with schizophrenia or schizoaffective disorder who receive multiple electroconvulsive therapy sessions: characteristics, indications, and results

BACKGROUND

While electroconvulsive therapy (ECT) has been used for many years, there is insufficient research regarding the indications for continuation/maintenance (C/M)-ECT, its safety and efficacy, and the characteristics of patients with schizophrenia or schizoaffective disorder who receive multiple ECT sessions. The aims of this study were to characterize a series of patients who received 30 ECT sessions or more, to describe treatment regimens in actual practice, and to examine the results of C/M-ECT in terms of safety and efficacy, especially the effect on aggression and functioning.

METHODS

We performed a retrospective chart review of 20 consecutive patients (mean age 64.6 years) with schizophrenia (n=16) or schizoaffective disorder (n=4) who received at least 30 ECT sessions at our ECT unit, and also interviewed the treating physician and filled out the Clinical Global Impression-Severity, Global Assessment of Functioning, and the Staff Observation Aggression Scale-Revised.

RESULTS

Patients received a mean of 91.3 ECT sessions at a mean interval of 2.6 weeks. All had been hospitalized for most or all of the previous 3 years. There were no major adverse effects, and cognitive side effects were relatively minimal (cognitive deficit present for several hours after treatment). We found that ECT significantly reduced scores on the Staff Observation Aggression Scale-Revised subscales for verbal aggression and self-harm, and improved Global Assessment of Functioning scores. There were reductions in total aggression scores, subscale scores for harm to objects and to others, and Clinical Global Impression-Severity scores, these were not statistically significant.

CONCLUSION

C/M-ECT is safe and effective for chronically hospitalized patients. It improves general functioning and reduces verbal aggression and self-harm. More research using other aggression tools is needed to determine its effects and to reproduce our findings in prospective and controlled studies.

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.

Frequency of electroconvulsive therapy sessions in a course

The frequency of sessions during a course of electroconvulsive therapy (ECT) is a topic of considerable interest for the practicing psychiatrist. In this narrative review, we examine the practice of and evidence-base for different schedules of ECT administration. A reasonable level of evidence is available to suggest that ECT administered twice weekly seems to have the best balance between therapeutic outcome and adverse effects in the immediate treatment of major depressive disorder while using bilateral ECT. Evidence also suggests that increasing the frequency of ECT may result in more rapid improvement of depression, but it increases adverse cognitive effects. However, very few data exist for comparing the merits and demerits of different frequencies of ECT administration during the immediate treatment of other disorders. There is also lack of research evidence to guide psychiatrists in deciding on the frequency of ECT administration during the continuation and maintenance phases.

Maintenance electroconvulsive therapy in autistic catatonia: a case series review

The usage of electroconvulsive therapy for the acute resolution of catatonia in autistic children and adults is a novel area that has received increased attention over the past few years. Reported length of the acute ECT course varies among these patients, and there is no current literature on maintenance ECT in autism. The maintenance ECT courses of three patients with autism who developed catatonia are presented. Clinical, research, legal, and administrative implications for ECT treatment in this special population are discussed.

Long-term weekly continuation electroconvulsive therapy: a case series

Despite best efforts with continuation pharmacotherapy, many patients relapse after a successful course of electroconvulsive therapy (ECT). Although maintenance ECT can be a useful and cost-effective treatment modality, there is considerable heterogeneity on how it is used. The authors report a case series of 3 patients ages 68, 43, and 81 years with diagnosis of schizoaffective disorder, bipolar disorder, and major depression with psychotic features who required weekly ECT treatments for several years. All attempts to space treatments led to rapid decompensation. None of the patients experienced clinical evidence of any treatment related cognitive or physical morbidity.

Adjusting the frequency of continuation and maintenance electroconvulsive therapy to prevent relapse of catatonic schizophrenia in middle-aged and elderly patients who are relapse-prone

The purpose of the present paper was to study the effect of continuation electroconvulsive therapy (ECT) on the prevention of relapse in middle-aged and elderly patients with intractable catatonic schizophrenia. It was found that continuation ECT is efficacious to sustain remission for patients who suffer relapse after response to acute ECT despite continuation neuroleptics. However, three patients suffered relapse during continuation ECT, therefore the effect of adjusting the frequency of continuation ECT and maintenance ECT was investigated in these patients with catatonic schizophrenia who relapsed during continuation ECT. These patients with DSM-IV catatonic schizophrenia who relapsed during continuation ECT were treated with more frequent continuation ECT and subsequent maintenance ECT after response to acute ECT. The patients' Brief Psychiatric Rating Scale (BPRS) scores were prospectively evaluated until relapse. Patients were considered to be relapsers if they had a BPRS score >or=37 for 3 consecutive days. The three patients with catatonic schizophrenia who relapsed during continuation ECT were treated successfully with more frequent continuation ECT and subsequent maintenance ECT. No patient experienced a severe adverse effect from continuation or maintenance ECT. More frequent continuation ECT and maintenance ECT deserves consideration in middle-aged and elderly patients with intractable catatonic schizophrenia who suffer relapse during continuation ECT. Large-scale systematic studies are warranted to investigate the optimum use of continuation and maintenance ECT in patients with catatonic schizophrenia.

[Electroconvulsive therapy as maintenance therapy and for prevention of recurrence in psychiatric disorders and Parkinson disease]

Electroconvulsive therapy is a reliable and safe option for patients with psychiatric disorders who are resistant or intolerant to medication as these patients usually respond quickly to this form of treatment. For clinicians, the management of these often severely ill patients is an important challenge given the high rate of relapse of these disorders. Maintenance electroconvulsive therapy is an interesting treatment option for these patients. Until now, only few controlled studies exist about the long-term outcome of this treatment in depressive disorders and other psychiatric disorders. Altogether, this form of outpatient prophylactic therapy has been found to be safe, well tolerated, and efficacious in relapse prevention. Moreover, it has been found to reduce hospitalization rates. Particularly in the elderly, and in patients who have been shown to be refractory to medication regimens, maintenance electroconvulsive therapy should be seriously considered as a means to reduce the risk of recurrence of illness. In Parkinson's disease maintenance electroconvulsive therapy is not widely established although its usefulness has been documented in numerous studies. First-line evidence data on incidence, dimensions and outcome of cognitive side effects under maintenance electroconvulsive therapy is still warranted.

Continuation and maintenance ECT: a review of recent research

Continuation and maintenance electroconvulsive therapy (ECT) is used to reduce the risk for relapse and recurrence of illness in patients who fare poorly with continuation and maintenance medication regimens. Despite the potential value of these ECT schedules, both are relatively neglected in clinical practice. This article therefore reviews the last decade of research on the subject. Although the research comprises mostly single and multiple case reports and small open studies, continuation and maintenance ECT does emerge as a safe and effective treatment for relapse- and recurrence-prone patients who have responded to a course of ECT.