ECT Can Help Patients With Medication-Resistant Schizophrenia

Dennis Skahill

Electroconvulsive therapy (ECT) is the oldest biological treatment in modern psychiatry. It is now more than 80 years old, and its efficacy in treating severe mental illness is unsurpassed.

Convulsive therapy was first introduced in 1934 by Ladislaus von Meduna in Hungary as a treatment for “dementia praecox,” the term for schizophrenia at the time. The first patient to receive the therapy had been diagnosed with dementia praecox and was catatonic and bedridden for years. The patient recovered completely after eight sessions of convulsive therapy in which seizures were induced with camphor oil (1-2).

The first treatment using electricity to induce a seizure was performed in 1938 in Rome by Ugo Cerletti and Lucio Bini on a patient exhibiting agitation, disorganization, neologisms, and delusions of thought control and broadcasting. He also recovered completely and, the new method of treating schizophrenia spread very quickly. ECT was introduced in the United States in 1939 by Lothar Kalinowski, a student of Cerletti and Bini, and was first offered as a clinical treatment in 1941 at Hillside Hospital in New York.

It soon became clear that ECT was extremely helpful not only for treating psychosis, but also conditions such as depression, mania, catatonia, delirium, epilepsy, and parkinsonian symptoms.

With the introduction of antipsychotics and antidepressants in the 1950s, the use of ECT declined. The antipsychiatry movements of the 1960s and 1970s in the Western world further decreased the use of ECT.

Over the past 30 years, however, the use of ECT has undergone an unprecedented revival due to its superior efficacy and safety in treating severe mental illnesses refractory to medications. While ECT in the United States today is a common treatment option for patients with treatment-resistant depression, it is often overlooked as a treatment option for patients with schizophrenia. In fact, patients with schizophrenia in the United States are less likely to receive ECT compared with patients in other parts of the world, even when medications do not work for them.

There are several factors contributing to the underutilization of ECT including stigma, limited availability of ECT in state and county hospitals, poor reimbursement, and limited knowledge of its effectiveness among medical and mental health professionals.

APA’s Task Force for ECT recommends the use of ECT for patients with schizophrenia who are catatonic and/or experiencing affective symptoms, considered to be suicidal, or failing to respond to medications (3).

Several studies over the last few years have sought to examine and document the efficacy of ECT alone or in combination with antipsychotic medications in people with schizophrenia. Most of the literature consists of observational studies and case series; however, there are several well-controlled studies that have been published on this issue. Among them, Worrawat Chanpattana and colleagues reported that 56 of 104 (54 percent) of patients with medication-resistant schizophrenia responded to a six-week course of ECT plus flupenthixol (4).

Our group at the Zucker Hillside Hospital recently published the results of a randomized, controlled, single-blinded trial, where we examined the efficacy of ECT as an augmentation strategy for patients who failed to respond to clozapine. In our sample, 10 of 20 patients (50 percent) responded after receiving ECT and clozapine for eight weeks (response was defined as 40 percent reduction in the psychotic items of the Brief Psychiatric Rating Scale [BPRS]). In contrast, none of the patients in the comparison group responded to clozapine monotherapy. An additional 47 percent (9 of 19) of patients responded to the ECT-clozapine combination in the crossover phase of the study, for a total of 49 percent (19/39) response rate to the ECT-clozapine combination (5). These findings suggest that patients who are resistant to clozapine—the only medication approved for medication-resistant schizophrenia—may benefit from ECT.

Wenzheng Wang and colleagues also recently published a meta-analysis of five randomized, single-blind, controlled trials comparing ECT alone with antipsychotic medications in patients with schizophrenia. They reported that as early as one to two weeks into therapy, ECT (n=153) outperformed antipsychotic monotherapy with a large effect size (-0.84 to -1.26) in psychopathology reduction as measured by the BPRS or the Positive and Negative Syndrome Scale (PANSS) (7). The findings support the combined use of antipsychotics and ECT.

The majority of ECT studies in schizophrenia report substantial benefits while there are no reports of worsening of psychopathology with ECT. Positive symptoms seem to respond better to ECT than negative symptoms, and the combination of ECT with antipsychotic medications seems to be superior to either modality, alone and there is no need for antipsychotic medication adjustment during ECT (8-9). The most common side effect reported is transient memory disturbance, which is similar to that observed in depression studies.

ECT is a powerful tool in our armamentarium for the treatment of schizophrenia and should be considered as the next step when results with medications are suboptimal. ■