Characteristics of schizophrenic patients and the outcome of fluphenazine and of electroconvulsive treatments

Effectiveness and clinical predictors of response to combined ECT and antipsychotic therapy in patients with treatment-resistant schizophrenia and dominant negative symptoms

The effectiveness and predictors of response to electroconvulsive therapy (ECT) combined with antipsychotics (AP) in treatment-resistant schizophrenia patients with the dominance of negative symptoms (TRS-NS) have not been studied systematically so far. 29 patients aged 21-55 years diagnosed with TRS-NS underwent ECT combined with antipsychotics (ECT+AP). Prior to the ECT, the symptom profile and severity were evaluated using Positive and Negative Syndrome Scale (PANSS). Demographic and medical data was collected; ECT parameters and pharmacotherapy results were evaluated. After the combined ECT+AP therapy a significant decrease in symptom severity was found. A response to treatment was achieved by 60% of patients. The greatest reductions were obtained in general and positive PANSS subscale (median change: 11 and 7 pts.) and the smallest, but still significant, ones in negative symptoms subscale (median: 3.5 pts.). Patients who responded to ECT+AP demonstrated a significantly shorter duration of the current episode in comparison with patients who did not experience at least a 25% reduction in symptom severity (median: 4 vs. 8 months). A combination of ECT and antipsychotic therapy can provide a useful treatment option for patients with TRS-NS. The only significant predictor of response to treatment was a shorter duration of the current episode.

ECT for treatment-resistant schizophrenia: a response from the far East to the UK. NICE report

BACKGROUND

There is controversy about the proper place of electroconvulsive therapy (ECT) in the management of the schizophrenic patient, and the important issues related to theory and practice remain to be resolved, especially in the context of medication-resistant schizophrenia.

METHOD

We briefly summarize existing research in the field. We next use a narrative method to describe in a single article the large body of research from Thailand that, during the past decade, has systematically studied issues related to the use of ECT in medication-resistant schizophrenia. We integrate the findings of the Thai efforts with the results of other research and consider the theoretical and practical importance of the reviewed work.

RESULTS

The ECT treatment data validate a BRPS cutoff of 25 as a definition of recovery in patients with treatment-refractory schizophrenia, and a cutoff of 37 as a definition of subsequent relapse or suitability for entry into a treatment protocol. A 3-week post-ECT stabilization period identifies patients who maintain improvement and who can be legitimately considered to have sustained response to ECT. Clinical characteristics of such responders and symptoms responsive to ECT are described. Higher stimulus dose hastens response to ECT but does not improve responsiveness. Continuation ECT (C-ECT) combined with maintenance-neuroleptic medication is associated with better treatment outcome than either treatment alone. The combined treatment also improves quality of life and functioning in the long-term.

CONCLUSIONS

These findings convey several useful thoughts for research into and the practice of ECT for schizophrenia.

World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of schizophrenia, Part 1: acute treatment of schizophrenia

These guide lines for the biological treatment of schizophrenia were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBO). The goal during the development of these guidelines was to review systematically all available evidence pertaining to the treatment of schizophrenia, and to reach a consensus on a series of practice recommendations that are clinically and scientifically meaningful based on the available evidence. These guidelines are intended for use by all physicians seeing and treating people with schizophrenia. The data used for developing these guidelines have been extracted primarily from various national treatment guidelines and panels for schizophrenia, as well as from meta-analyses, reviews and randomised clinical trials on the efficacy of pharmacological and other biological treatment interventions identified by a search of the MEDLINE database and Cochrane Library. The identified literature was evaluated with respect to the strength of evidence for its efficacy and then categorised into four levels of evidence (A-D). This first part of the guidelines covers disease definition, classification, epidemiology and course of schizophrenia, as well as the management of the acute phase treatment. These guidelines are primarily concerned with the biological treatment (including antipsychotic medication, other pharmacological treatment options, electroconvulsive therapy, adjunctive and novel therapeutic strategies) of adults suffering from schizophrenia.

Mechanisms of action of ECT: schizophrenia and schizoaffective disorder

A variety of neurophysiological mechanisms have been suggested to explain the therapeutic action of electroconvulsive therapy (ECT). Processes of kindling, resolution of hemispheric dysfunctions, anticonvulsant effects, and diencephalic stimulation all have been proposed to account for the beneficial effects of ECT. To investigate these, we analyzed clinical, neuropsychological, and electroencephalographic (EEG) data from 110 ECT-treated patients with schizophrenia and schizoaffective disorders, comparing responders with nonresponders. Fifty-four percent of all the patients were rated as very much or much improved. Mechanisms of kindling or anticonvulsant effects were not supported by the data. Dominant hemispheric dysfunctions in schizophrenics were suggested by the neuropsychological test data. There was tenuous support for the sensitization theory and both the neuropsychological and EEG data contradicted the dominant accentuation theory. Taken together with our previous report on ECT-treated patients with affective disorders, we propose that ECT might act by restoration of equilibrium between the hemispheres.

The positive triad of schizophrenic symptoms. Its statistical properties and its relationship to 13 traditional diagnostic systems

Using data from the WHO International Pilot Study of Schizophrenia and from our own previously reported series of 120 patients receiving treatment for schizophrenia, we ascertained the degree of agreement between 13 different systems for diagnosing schizophrenia. We identified a triad of symptoms similar to that from the International Pilot Study: auditory hallucinations, passivity feelings, and disturbances of affect. This triad correlated very strongly with the diagnosis of schizophrenia as determined by the 13 diagnostic systems, as well as with response to fluphenazine in our series. The triad should serve as a core set of symptoms in the study of schizophrenic illness. It represents the leading phenomena in a group of patients having what is generally considered to be schizophrenia, although it does not provide a definitive diagnosis. Evidence is needed on its specificity.