Combination of Electroconvulsive Therapy and Clozapine in Treatment-Resistant Schizophrenia

Behavioral and transcriptional effects of repeated electroconvulsive seizures in the neonatal MK-801-treated rat model of schizophrenia

RATIONALE

Electroconvulsive therapy (ECT) is an effective treatment modality for schizophrenia. However, its antipsychotic-like mechanism remains unclear.

OBJECTIVES

To gain insight into the antipsychotic-like actions of ECT, this study investigated how repeated treatments of electroconvulsive seizure (ECS), an animal model for ECT, affect the behavioral and transcriptomic profile of a neurodevelopmental animal model of schizophrenia.

METHODS

Two injections of MK-801 or saline were administered to rats on postnatal day 7 (PN7), and either repeated ECS treatments (E10X) or sham shock was conducted daily from PN50 to PN59. Ultimately, the rats were divided into vehicle/sham (V/S), MK-801/sham (M/S), vehicle/ECS (V/E), and MK-801/ECS (M/E) groups. On PN59, prepulse inhibition and locomotor activity were tested. Prefrontal cortex transcriptomes were analyzed with mRNA sequencing and network and pathway analyses, and quantitative real-time polymerase chain reaction (qPCR) analyses were subsequently conducted.

RESULTS

Prepulse inhibition deficit was induced by MK-801 and normalized by E10X. In M/S vs. M/E model, Egr1, Mmp9, and S100a6 were identified as center genes, and interleukin-17 (IL-17), nuclear factor kappa B (NF-κB), and tumor necrosis factor (TNF) signaling pathways were identified as the three most relevant pathways. In the V/E vs. V/S model, mitophagy, NF-κB, and receptor for advanced glycation end products (RAGE) pathways were identified. qPCR analyses demonstrated that Igfbp6, Btf3, Cox6a2, and H2az1 were downregulated in M/S and upregulated in M/E.

CONCLUSIONS

E10X reverses the behavioral changes induced by MK-801 and produces transcriptional changes in inflammatory, insulin, and mitophagy pathways, which provide mechanistic insight into the antipsychotic-like mechanism of ECT.

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.

Mirror-Image Comparison of Maintenance Electroconvulsive Treatment Effectiveness in Affective and Psychotic Disorders

OBJECTIVES

The study aimed to investigate the effectiveness of maintenance electroconvulsive therapy (mECT) with respect to the hospitalization duration, number of hospitalizations, and major and minor treatment changes with a mirror-image study design.

METHODS

Medical charts of patients who received at least a 3-month-long course of mECT were reviewed. The records of 36 patients (17 with psychotic disorders, 19 with affective disorders) were retrospectively examined for 2 periods with the same duration; during the mECT (post-mECT) and before the mECT (pre-mECT). The hospitalization duration, the number of hospitalizations, and major and minor treatment changes, which were assumed to provide information on the effectiveness of the interventions, were recorded and compared between these periods. Statistical analysis was performed using generalized estimating equation models conducted with age, diagnostic category, and observation time as covariates. In addition, the relapse and recurrence rates and time to relapse/recurrence were analyzed.

RESULTS

Comparison of pre-mECT and post-mECT periods revealed that mECT, applied in an individualized schedule combined with pharmacotherapy, was associated with a lower frequency ( P < 0.001; rate ratio [RR], 0.161; 95% confidence interval [CI], 0.087-0.297), shorter duration of hospitalization ( P < 0.001; RR, 0.123; 95% CI, 0.056-0.271), and lower number of major treatment changes ( P = 0.007; RR, 0.522; 95% CI, 0.324-0.840), irrespective of diagnoses. The relapse/recurrence rates were similar in the 2 diagnostic categories ( P = 1.000; 26.3% vs 29.4%).

CONCLUSIONS

Maintenance ECT should be increasingly considered an important treatment modality in patients with affective and psychotic disorders after an effective course of ECT.

Morbidity Due to Disparity in Pediatric Electroconvulsive Therapy

Dr. Miller and colleagues recently submitted a Letter to the Editor discussing current state laws that result in disparity of electroconvulsive therapy (ECT) availability.¹ In this current letter, we present a case of treatment-resistant childhood-onset schizophrenia (COS), with morbidity due to limited access to ECT. The patient and his family presented from Kentucky to Tennessee, despite less legislative regulation in the former. The patient's family provided informed consent for this report to be published.

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.

Impact of medications, mood state, and electrode placement on ECT outcomes in treatment-refractory psychosis

BACKGROUND

Treatment-refractory psychosis (TRP) is a significant clinical challenge. While clozapine is frequently effective, alternate or augmentation strategies are often necessary. Evidence supports effectiveness of electroconvulsive therapy (ECT), but questions remain about optimal treatment parameters and impacts of concomitant pharmacotherapy.

OBJECTIVE

/Hypothesis: To analyze the impact of clozapine, anticonvulsant medication, mood state, and ECT electrode placement on outcomes in TRP. We hypothesized that ECT would lead to greater reduction in positive symptoms, particularly in patients receiving clozapine.

METHODS

Retrospective study in a tertiary TRP program. The Positive and Negative Syndrome Scale (PANSS) was used for clinical outcomes, with positive subscore as primary outcome. Clinical and ECT data were analyzed using a linear modelling approach, controlling for relevant covariates.

RESULTS

A total of 309 patients were included. ECT plus clozapine associated with greater improvement in positive, general, and total symptoms than ECT alone. ECT associated with greater improvement in negative symptoms in depressed patients. Bifrontal placement was mostly equivalent to bitemporal, with greater reduction of positive symptoms in patients receiving clozapine, and associated with lower electrical dose in patients on anticonvulsants. Clozapine increased seizure duration, while anticonvulsants decreased it. Anticonvulsant use in ECT patients associated with equivalent to slightly improved symptom reduction.

CONCLUSIONS

ECT's benefit in TRP may be greatest in patients receiving clozapine. ECT can improve negative symptoms in depressed TRP patients. Bifrontal placement is effective in TRP. Clozapine and anticonvulsants have opposite effects on seizure duration, but anticonvulsants may not adversely affect clinical outcomes of ECT for TRP.

Machine Learning Algorithm-Based Prediction Model for the Augmented Use of Clozapine with Electroconvulsive Therapy in Patients with Schizophrenia

The augmentation of clozapine with electroconvulsive therapy (ECT) has been an optimal treatment option for patients with treatment- or clozapine-resistant schizophrenia. Using data from the Research on Asian Psychotropic Prescription Patterns for Antipsychotics survey, which was the largest international psychiatry research collaboration in Asia, our study aimed to develop a machine learning algorithm-based substantial prediction model for the augmented use of clozapine with ECT in patients with schizophrenia in terms of precision medicine. A random forest model and least absolute shrinkage and selection operator (LASSO) model were used to develop a substantial prediction model for the augmented use of clozapine with ECT. Among the 3744 Asian patients with schizophrenia, those treated with a combination of clozapine and ECT were characterized by significantly greater proportions of females and inpatients, a longer duration of illness, and a greater prevalence of negative symptoms and social or occupational dysfunction than those not treated. In the random forest model, the area under the curve (AUC), which was the most preferred indicator of the prediction model, was 0.774. The overall accuracy was 0.817 (95% confidence interval, 0.793−0.839). Inpatient status was the most important variable in the substantial prediction model, followed by BMI, age, social or occupational dysfunction, persistent symptoms, illness duration > 20 years, and others. Furthermore, the AUC and overall accuracy of the LASSO model were 0.831 and 0.644 (95% CI, 0.615−0.672), respectively. Despite the subtle differences in both AUC and overall accuracy of the random forest model and LASSO model, the important variables were commonly shared by the two models. Using the machine learning algorithm, our findings allow the development of a substantial prediction model for the augmented use of clozapine with ECT in Asian patients with schizophrenia. This substantial prediction model can support further studies to develop a substantial prediction model for the augmented use of clozapine with ECT in patients with schizophrenia in a strict epidemiological context.

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.

Increased subcortical region volume induced by electroconvulsive therapy in patients with schizophrenia

Electroconvulsive therapy (ECT) has been widely used to treat patients with schizophrenia. However, the underlying mechanisms of ECT remain unknown. In the present study, the treatment effects of ECT on brain structure in patients with schizophrenia were explored. Seventy patients with schizophrenia were scanned using structural magnetic resonance imaging. Patients in the drug group were scanned at baseline (time 1) and follow-up (time 2, 6 weeks of treatment). Patients in the ECT group were scanned before ECT treatment (baseline, time 1) and 10-12 h after the last ECT treatment (time 2). Voxel-based morphometry was applied to analyze the imaging data. Patients in the ECT group showed significantly increased gray matter volume (GMV) in the bilateral hippocampus/amygdala and left superior temporal gyrus (STG)/middle temporal gyrus (MTG) after ECT combined with antipsychotic therapy at time 2. In contrast, patients in the drug group showed decreased GMV in widespread brain regions. Correlation analysis results showed significantly negative correlations between the increased GMV in the bilateral hippocampus/amygdala and PANSS scores at baseline in the ECT group. ECT may modulate brain structure in patients with schizophrenia. The GMV in distinct subcortical regions was related to the individual therapeutic response in patients with schizophrenia.

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.

Resolution of Persistent Auditory Verbal Hallucinations after Long-term Electroconvulsive Therapy Maintenance: A Case Report of a Patient with Clozapine-resistant Schizophrenia

A 32-year-old woman with schizophrenia and persistent auditory verbal hallucinations (AVHs), which caused continuous suicidal thoughts and depression, was treated with electroconvulsive therapy (ECT) of an acute course followed by maintenance ECT (M-ECT) augmented onto clozapine for 7 years. Although the general psychopathology and AVHs initially reduced slightly with ECT and clozapine, her AVHs and suicidal thoughts did not decrease subjectively. When 3 years of M-ECT, her voices declined sharply, and improvement was maintained for 2 years thereafter. A total 91 ECT sessions were performed. The daily clozapine dose was decreased from 325 to 200 mg and plasma levels remained higher than 350 ng/ml; there were no noticeable cognitive side effects. In summary, we report a case showing a sudden sharp reduction in persistent AVHs after 3 years of long-term M-ECT.

Long-term clinical efficacy of maintenance electroconvulsive therapy in patients with treatment-resistant schizophrenia on clozapine

Electroconvulsive therapy (ECT) has been suggested as a treatment for augmenting the response to clozapine in patients that do not respond well to clozapine alone and maintenance ECT (M-ECT) had also been recommended to sustain improvement. This retrospective study of up to 2 years of observation was conducted to explore whether M-ECT is beneficial for long-term maintenance of the symptom remission elicited by acute ECT. Positive and Negative Syndrome Scale (PANSS) were plotted for each patient and compared using a linear mixed-effect model. A total of thirty-eight patients were followed and classified into three groups: (1) clozapine alone (CZP, n = 15), (2) acute ECT only (A-ECT, n = 11), and (3) acute ECT with M-ECT (M-ECT, n = 12). The mean number and interval of ECT sessions during the maintenance period in the M-ECT group were 39.0 ± 26.7 and 15.6 ± 8.4 days, respectively. The slope of the M-ECT group eventually declined, but that of the A-ECT group gradually increased back to the pre-ECT level. No persistent or serious adverse effects were observed. In conclusion, A-ECT augmented the effect of clozapine, but M-ECT was required for sustaining symptom improvement.