Indications for electroconvulsive treatment in schizophrenia: A systematic review

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Abstract

Background

Electroconvulsive therapy (ECT) is a medical treatment that is most effective for mood disorders (Bipolar Disorder and Major Depression). It has also been shown to be an effective treatment for schizophrenia accompanied by catatonia, extreme depression, mania and other affective components. ECT is currently under-used in many psychiatric settings due to its stigmatized perception by patients and mental health professionals. However, many unanswered questions remain regarding its role in the management of patients with schizophrenia.

Aim

Evaluate the main indications of ECT in subjects suffering from schizophrenia.

Objectives

Investigate the efficacy and the main indications of ECT in the treatment of schizophrenic patients, evaluate its effects in the short-term and the long-term, compare ECT treatment with pharmacotherapy, and assess the effects of treatment with ECT.

Methods

A systematic review of the literature was conducted on the use of ECT for schizophrenia. Thirty one articles from peer-reviewed journals were identified, and the most relevant articles were selected for this review.

Results

The most common indication for using ECT for schizophrenia patients was to augment pharmacotherapy, while the most common accompanying symptoms were, in order, catatonia, aggression and suicide. Catatonic patients responded significantly better to ECT than patients with any other subtype of schizophrenia. The combination of ECT with pharmacotherapy can be useful for drug-resistant patients. The use of an ECT-risperidone combination or ECT-clozapine combination in patients non-responsive to prior pharmacotherapy was found to be most effective.

Conclusions

This review indicates that ECT, combined with pharmacotherapy, may be a viable option for a selected group of patients with schizophrenia. In particular, the use of ECT is recommended for drug-resistant patients, for schizophrenic patients with catatonia, aggression or suicidal behavior, and when rapid global improvement and reduction of acute symptomatology are required.

Introduction

Electroconvulsive therapy (ECT) is a medical treatment that is effective for mood disorders (Bipolar Disorder and Major Depression). In 1938, Ugo Cerletti and Lucio Bini, two Italian psychiatrists, were the first to use anticonvulsant therapy in the field of psychiatry, and the first patient given the treatment had a psychotic disorder (Cerletti, 1950). In 1950, the introduction of neuromuscular blocking drugs led to a reduction of side effects (Bennett, 1972) and improved the toleration of ECT by patients (Clare, 1980). The patient is monitored for the duration of the treatment and awakens after a few minutes. The patient does not usually remember the treatment. Upon waking, the main side-effects are headaches, confusion, memory loss (retrograde amnesia) and difficulty in storing information (Frankel, 1984), but these side-effects tend to dissipate with the passage of time, although there are individual variations in this (Frankel, 1984). The use of ECT declined after the introduction of antipsychotic drugs, and its use has been limited to patients who are resistant to pharmacotherapy (Fink and Sackeim, 1996).

Recent studies have shown that a combination of ECT and antipsychotics has a significant advantage in terms of rapidity and quality of response (Taylor and Fleming, 1980, Janakiramaiah et al., 1982, Ungvari and Petho, 1982, Abraham and Kulhara, 1987, Sarita et al., 1998). Treatment guidelines from the American Psychiatric Association (Weiner et al., 2001) suggest that ECT can be used in the treatment of schizophrenia for catatonia, in patients with a past history of a good response to ECT, and for treatment-resistance to medication. According to some studies, ECT may also be useful for schizophrenic patients with acute suicidal risk (Greenblatt, 1977, Tsuang et al., 1979). The aim of the present paper was to investigate the main indications for the use of electroconvulsive treatment in patients with schizophrenia.

Section snippets

Selection criteria and quality assessment

In order to provide a new and timely systematic review about the main indications for using ECT with patients with schizophrenia, following the PRISMA statement for reporting systematic reviews (Liberati et al., 2009), we performed a careful MedLine, Excerpta Medica, PsycLit, PsycInfo and Index Medicus search to identify all papers and book chapters in English for the period of 1945 to 2012. The following search terms were used: “ECT*” (which comprises electro-convulsive therapy, electroshock

Real versus sham ECT

Seven studies have compared ECT plus antipsychotics against sham ECT plus antipsychotics in schizophrenia patients (Naidoo, 1956, Taylor and Fleming, 1980, Abraham and Kulhara, 1987, Brandon et al., 1985, Sarkar et al., 1994, Sarita et al., 1998, Goswami et al., 2001). The effectiveness of ECT over sham ECT may be obscured by concomitant treatment with antipsychotics, which are indisputably effective in improving the symptoms of schizophrenia. Three studies did not use antipsychotics in

Discussion

From this review, it appears that ECT is effective and safe for reducing acute symptoms (such as first acute crisis, catatonia and suicidal behavior) in patients with schizophrenia (Small et al., 1982, Abraham and Kulhara, 1987, Suzuki et al., 2006, Thirthally et al., 2009, Puthane et al., 2011) and for improving the quality of life (Garg et al., 2011). ECT appears to be a good alternative for treatment-resistant patients (Small et al., 1982, Abraham and Kulhara, 1987, Abraham and Kulhara, 1987

Conclusion

The most common indication for ECT in schizophrenia is to augment the effect of antipsychotics and to resolve acute symptoms (catatonia, aggression and suicidal behavior). ECT can be valuable for the treatment for patients with schizophrenia in a suicidal crisis, especially in the short-term, although the results of research on this issue are not altogether consistent. Bifrontal electrode placement appears to be more effective than bitemporal electrode placement, resulting in fewer cognitive

Role of the funding source

Supported, in part, by a grant from the Italian Ministry of University Research-PRIN Project.

Contributors

Drs Pompili, Lester and Dominici designed the study and performed systematic searches. Drs. Marconi and Longo contributed in drafting the paper and extracting the main findings of the study. Drs. Serafini, Amore and Girardi provided the supervision and interpretation of results All authors contributed in drafting the paper.

Conflict of interest

None.

Acknowledgment

None.

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