Electroconvulsive Therapy for Treatment-Resistant Schizophrenia

Sinclair, Diarmid J M; Zhao, Shuo; Qi, Fang; Nyakyoma, Kazare; Kwong, Joey S.W.; Adams, Clive E

doi:10.1093/schbul/sbz037

Cited by 37 publications

(24 citation statements)

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“…The evidence for other brain stimulation approaches for the treatment of negative symptoms remains very limited. While electroconvulsive therapy has shown promising effects on overall and positive symptoms in treatment-resistant schizophrenia, the evidence for a reduction of negative symptoms [63][64][65] is very limited and no recommendation can be given at this point.…”

Section: Other Brain Stimulation Techniquesmentioning

confidence: 99%

EPA guidance on treatment of negative symptoms in schizophrenia

et al. 2021

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Negative symptoms of schizophrenia remain a major therapeutic challenge. The progress in the conceptualization and assessment is not yet fully reflected by treatment research. Nevertheless, there is a growing evidence base regarding the effects of biological and psychosocial interventions on negative symptoms. The importance of the distinction between primary and secondary negative symptoms for treatment selection might seem evident, but the currently available evidence remains limited. Good clinical practice is recommended for the treatment of secondary negative symptoms. Antipsychotic treatment should be optimized to avoid secondary negative symptoms due to side effects and due to positive symptoms. For most available interventions, further evidence is needed to formulate sound recommendations for primary, persistent, or predominant negative symptoms. However, based on currently available evidence recommendations for the treatment of undifferentiated negative symptoms (including both primary and secondary negative symptoms) are provided. Although it has proven difficult to formulate an evidence-based recommendation for the choice of an antipsychotic, a switch to a second-generation antipsychotic should be considered for patients who are treated with a first-generation antipsychotic. Antidepressant add-on to antipsychotic treatment is an option. Social skills training is recommended as well as cognitive remediation for patients who also show cognitive impairment. Exercise interventions also have shown promise. Finally, access to treatment and to psychosocial rehabilitation should be ensured for patients with negative symptoms. Overall, there is definitive progress in the field, but further research is clearly needed to develop specific treatments for negative symptoms.

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Section: Other Brain Stimulation Techniquesmentioning

confidence: 99%

EPA guidance on treatment of negative symptoms in schizophrenia

et al. 2021

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“…While there is considerable clinical trial, case series, and case report material to support the use of an acute course of ECT in patients with schizophrenia , the totality of the evidence has been inadequate to convince either the US FDA or the Cochrane Database that ECT should be among the standard treatments: ‘Moderate‐quality evidence indicates that relative to standard care, ECT has a positive effect on medium‐term clinical response for people with treatment‐resistant schizophrenia. However, there is no clear and convincing advantage or disadvantage for adding ECT to standard care for other outcomes’ .…”

Section: Indicationsmentioning

confidence: 99%

When to consider electroconvulsive therapy (ECT)

Kellner

Obbels

Sienaert

2019

Acta Psychiatr Scand

133

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When to consider electroconvulsive therapy (ECT) Kellner CH, Obbels J, Sienaert P. When to consider electroconvulsive therapy (ECT).Objective: To familiarize the reader with the role of electroconvulsive therapy (ECT) in current psychiatric medicine. Method: We review clinical indications for ECT, patient selection, contemporary ECT practice, maintenance treatment and ECT in major treatment guidelines. Results: ECT is underutilized largely due to persisting stigma and lack of knowledge about modern ECT technique. Conclusion: ECT remains a vital treatment for patients with severe mood disorders, psychotic illness and catatonia. Clinical recommendations for ECT• ECT should be prescribed earlier in the course of a severe depressive episode, not necessarily withheld until after numerous medication trials • ECT may be considered a first-line (primary) treatment for certain urgently ill patients, including those who are very suicidal, psychotic, or physically debilitated from depression Diagnostic indications for ECT • In many Western countries, severe and treatment-resistant depression is the main indication for ECT • Schizophrenia is the number one indication for ECT worldwide, but is little used for this indication in Western countries • ECT is an effective treatment for treatment-resistant mania • Delirious mania is an urgent indication for ECT • ECT is effective for treatment-resistant schizophrenia, including clozapine-resistant illness • Catatonia is very responsive to ECT • Both the motor and behavioural symptoms of Parkinson's disease respond to ECT Predictors of ECT response • Older age, psychotic symptoms, and shorter episode duration are predictors of better ECT response • Melancholic features and greater baseline depressive symptom severity are likely associated with better ECT response 304 ECT technique • Bilateral, bifrontal, and right unilateral electrode placement are all effective ECT techniques • Less urgently ill patients are often treated initially with right unilateral electrode placement • Brief and ultrabrief pulse width stimuli, now commonly used, are associated with a more benign cognitive effect profile • There is no a priori fixed number of ECT in an acute course: patients should continue treatment with ECT until they remit or a plateau has been reached, or tolerability issues require interruption of the course • Tapering of acute courses of ECT should be considered for most patients (e.g., approximately weekly treatments for several weeks past remission) • Continuation/Maintenance (C/M) ECT should be considered for patients with a history of severe, recurrent episodes who have failed to remain well on medications Additional comments • ECT is underutilized because of stigma, lack of knowledge about it, and bureaucratic restrictions • ECT is among the safest procedures performed under general anesthesia • Cognitive adverse effects are markedly decreased with modern ECT techniques, largely transient, and should not deter seriously ill patients from considering ECT.

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“…While not forming part of current definitions of treatment resistance, we added a requirement that the patients had been treated with ECT at some point without sustained improvement, unless this treatment was contra-indicated or not tolerated or had been refused. This was in the interests of focusing on patients in whom all other potentially effective treatment options had been tried [22].…”

Section: Implications Of All the Available Evidencementioning

confidence: 99%

Deep brain stimulation in treatment resistant schizophrenia: A pilot randomized cross-over clinical trial

et al. 2020

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Background: Up to 30% of patients with schizophrenia are resistant to antipsychotic drug treatment, with 60% of such cases also failing to respond to clozapine. Deep brain stimulation (DBS) has been used in treatment resistant patients with other psychiatric disorders, but there is a lack of trials in schizophrenia, partly due to uncertainties over where to site the electrodes. This trial aimed to examine the effectiveness of nucleus accumbens (NAcc) and subgenual anterior cingulate cortex (subgenual ACC) targeted DBS; the primary outcome measure was PANSS total score, as assessed fortnightly. Methods: Eight patients with schizophrenia, who met criteria for treatment resistance and were also resistant to/ intolerant of clozapine, were randomly assigned using central allocation to receive DBS in the NAcc or subgenual ACC. An open stabilization phase lasting at least six months was followed by a randomized double-blind crossover phase lasting 24 weeks in those who met symptomatic improvement criteria. The primary end-point was a 25% improvement in PANSS total score. (ClinicalTrials.gov Identifier: NCT02377505; trial completed). Findings: One implanted patient did not receive DBS due to complications of surgery. Of the remaining 7 patients, 2/3 with NAcc and 2/4 with subgenual ACC electrode placements met the symptomatic improvement criteria (58% and 86%, and 37% and 68% improvement in PANSS total score, respectively). Three of these patients entered the crossover phase and all showed worsening when the stimulation was discontinued. The fourth patient worsened after the current was switched off accidentally without her or the investigators' knowledge. Physical adverse events were uncommon, but two patients developed persistent psychiatric adverse effects (negative symptoms/apathy and mood instability, respectively). Interpretation: These preliminary findings point to the possibility of DBS having therapeutic effects in patients with schizophrenia who do not respond to any other treatment. Larger trials with careful attention to blinding will be necessary to establish the extent of the benefits and whether these can be achieved without psychiatric side-effects.

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Electroconvulsive Therapy for Treatment-Resistant Schizophrenia

Cited by 37 publications

References 1 publication

EPA guidance on treatment of negative symptoms in schizophrenia

EPA guidance on treatment of negative symptoms in schizophrenia

When to consider electroconvulsive therapy (ECT)

Deep brain stimulation in treatment resistant schizophrenia: A pilot randomized cross-over clinical trial

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