Very High-Dose Clozapine and Electroconvulsive Therapy Combination Treatment in a Patient With Schizophrenia

Abstract

We report here the case of a 19-year-old man with paranoid schizophrenia who responded only partially to treatment with daily doses of clozapine, 1800 mg; aripiprazole, 20 mg; and clonazepam, 6 mg. We reduced the clozapine to 1600 to 1700 mg, maintaining therapeutic serum levels, and added a course of electroconvulsive therapy that included 24 treatments. Therapeutic results were minimal. However, adverse effects were limited to mild cognitive disturbances. Our experience adds to other reports suggesting that clozapine and electroconvulsive therapy can be combined without causing excessive adverse effects.

Augmentation of clozapine with electroconvulsive therapy in treatment resistant schizophrenia: A systematic review and meta-analysis

“…Supplementary Table 1 gives an overview of case series included (n=6) (Benatov et al, 1996;Cardwell and Nakai, 1995;Frankenburg et al, 1993;Grover et al, 2015;Kales et al, 1999;Kurian et al, 2005). Supplementary Table 2 provides an overview of included case reports (n=15) (Bannour et al, 2014;Bhatia et al, 1998;Biedermann et al, 2011;Gerretsen et al, 2011;Husni M, 1999;Keller et al, 2009;Klapheke, 1991;Lee et al, 2008;Manjunatha et al, 2011;Safferman and Munne, 1992;Sienaert et al, 2004;Sinha and Shah, 2013;Vowels et al, 2014;Yoshino et al, 2014) (Manjunatha et al, reported on two individual case reports). Overall, these studies and reports include a total of 192 patients with a diagnosis of treatment resistant schizophrenia or schizoaffective disorder treated with C+ECT.…”

“…The mean number of ECT treatments used in the controlled (n-2) and open label trials (n=4) was 13.0 (for total n=77). The mean clozapine dose used was 412.3 mg daily (for n=127 patients), with a mean serum clozapine level of 772.6ng/ml (recorded for n=52 patients treated with an average clozapine dose of 506.9 mg daily (Gerretsen et al, 2011;Keller et al, 2009;Kho et al, 2004;Petrides et al, 2015)). In those non-controlled studies, case series and case reports with follow up data, a relapse rate of 32% (20 out of 62 patients), was identified following an initial response to clozapine augmentation with ECT.…”

Combined use of clozapine and ECT: a review

“…In terms of response to the combined treatment, the evidence from case reports suggests that the combined treatment leads to reduction in psychopathology; however, in only occasional reports, standard rating scales have been used (31,40,43,44). Some case reports have included patients with schizophrenia with intellectual disability, (42) and in terms of specific symptoms some of the reports suggest improvement in violent (45) and self-injurious behaviour (46).…”

Delayed Onset, Protracted Delirium and Aspiration Pneumonitis Associated with a Combination of Clozapine and Electroconvulsive Therapy

“…The efficacy and safety of electroconvulsive therapy (ECT) augmentation of clozapine has been reported earlier. [3][4][5][6][7][8][9][10][11][12][13][14] The immediate post-ECT delirium is self-limiting and transient, requiring no active intervention. Reports on delayed onset and prolonged delirium after ECT, which might require a different plan of management, are scarce.…”