Combined Clozapine and Electroconvulsive Therapy in Clozapine-Resistant Schizophrenia

Abstract

For treatment-refractory schizophrenia, electroconvulsive therapy (ECT) remains controversial because of its cognitive adverse effects. We report here on clinical and cognitive outcomes of a treatment-resistant schizophrenia patient treated with clozapine and right unilateral ECT.The patient was administered 300 mg of clozapine and 12 right unilateral ECT sessions. Psychopathology was rated by means of the Positive and Negative Syndrome Scale. The neurocognitive test battery included the Wisconsin Card Sorting Test, the Münchner Gedächtnis Test, an attentional performance test, the Trail Making Test, and the Hamburger-Wechsler Intelligence Test.The Positive and Negative Syndrome Scale total score decreased, and all cognitive measures improved.Electroconvulsive therapy would seem to be a safe treatment option for treatment-refractory schizophrenia patients.

Effectiveness and clinical predictors of response to combined ECT and antipsychotic therapy in patients with treatment-resistant schizophrenia and dominant negative symptoms

“…The authors also concluded that ECT can be a safe and efficacious treatment strategy for patients refractory to conventional treatments. Nearly all case histories (Safferman and Munne, 1992;Benatov et al, 1996;Bhatia et al, 1998;James and Gray, 1999;Kales et al, 1999;Biedermann et al, 2011), clinical studies and meta-analyses (Bondolfi et al, 1998;Masoudzadeh and Khalilian, 2007;Porcelli et al, 2012) confirm effectiveness of combining clozapine with ECT in treatment resistant schizophrenia patients. Few studies describe safety and effectiveness of ECT combined with other second generation antipsychotics.…”

“…This observation is in line with other studies. In the literature significant adverse effects of the combination treatment were not found (Bondolfi et al, 1998;Tang and Ungvari, 2002;Nothdurfter et al, 2006;Masoudzadeh and Khalilian, 2007;Biedermann et al, 2011;Takacs et al, 2013).…”

“…Several studies and meta-analyses showed efficacy and safety of ECT þAP therapy in patients with TRS (Painuly and Chakrabarti, 2006). Mainly first generation antipsychotics or clozapine were used in the conducted studies (Chanpattana et al, 1999b;Biedermann et al, 2011). Only a limited number of papers can be found on the combined use of ECT and second generation antipsychotics (SGAs) (Tang and Ungvari, 2002;Masdrakis et al, 2008b;Ravanic et al, 2009;Masdrakis et al, 2010;Takacs et al, 2013).…”

Combined use of clozapine and ECT: a review

“…Some of the recent studies have specifically assessed cognitive functions of patients receiving the combined treatment and One patient remained well for at least 6 weeks on clozapine after completion of ECT One patient remained weak with maintenance ECT and clozapine for 2 months Klapheke (15) Schizoaffective disorder, mania 1 Remained well for at least 3 weeks on clozapine after completion of ECT Safferman and Munne (54) Schizophrenia 1 Remained well for at least 3 weeks on clozapine after completion of ECT Factor et al (30) Psychosis related to Parkinson's disease Only one of the six patients became disturbed again after 6 months Kales et al (31) Schizophrenia (four of the five patients were clozapine-resistant) 5 Improvement sustained for less than 4 months in three of the five patients Long-term outcome -not good for most patients Chanpattana et al (52) Bipolar disorder, mania 1 Improved, maintained well for the 18-month period Kho et al (26) Schizophrenia (clozapine nonresponders) 11 During the mean follow-up duration of 16 (range 4-42) weeks, five patients had relapse of symptoms after the initial response. Relapse occurred between week 3 and 19 Of those who relapsed, three of the five patients received a second ECT course and remained well with maintenance ECT and clozapine (17) 1 Prolonged Seizure (123 s) followed by two GTCS on day 4 and 6 (n = 1) after ECT Safferman and Munne (54) 1 Tachycardia, hypertension Beale et al (32) 1 Supraventricular tachycardia (died 3 weeks after last ECT) Kales et al (36) 15 Significant tachycardia (n = 1) Bloch et al (18) 1 Prolonged seizure (6-min long terminated by diazepam) (n = 1) Poyurovsky and Weizman (50) 2 30% prolongation in seizure after start of ECT (n = 1) Godeman and Hellweg (51) 1 Delirium while on maintenance ECT and clozapine 50 mg/day Bhatia et al have actually reported no change (29,40,57) or improvement in the same. Overall, from the available evidence, it can be concluded that the risk for prolonged seizure is possibly not very high.…”

“…In most of these reports, ECT was considered after the use of clozapine, with some of the reports specifying that the patients were considered clozapine non-responsive before being considered for augmentation with ECT (26,27,29,31,36,(39)(40)(41). However, occasionally, some reports mentioned the use of clozapine following the use of ECT (18).…”