Combined use of electroconvulsive therapy and antipsychotics (both clozapine and non-clozapine) in treatment resistant schizophrenia: A comparative meta-analysis

Abstract

AimTo assess the relative efficacies of clozapine plus Electroconvulsive Therapy (ECT) compared against non-clozapine typical and atypical antipsychotics plus ECT for the treatment of “Treatment Resistant Schizophrenia” (TRS). Primarily to assess if clozapine delivers a significant improvement over other antipsychotics when combined with ECT.DesignMajor electronic databases were searched between 1990 and March 2017 for trials measuring the effects of either clozapine augmented ECT, other antipsychotic-augmented ECT, or both. After the systematic review of the data, a random-effects meta-analysis was conducted measuring the relative effect sizes of the different treatment regimens.Subjects1179 patients in 23 studies reporting the usage of ECT augmentation with antipsychotics. A total of 95 patients were tested with clozapine, and ECT (9 studies) and 1084 patients were tested with non-clozapine antipsychotics (14 studies) such as flupenthixol, chlorpromazine, risperidone, sulpiride, olanzapine, and loxapine with concurrent ECT treatment considered for systematic review. Of these, 13 studies reported pre and post-treatment scores were included in the meta-analysis.Main outcome measuresThe main outcome measure was the presence and degree of both positive and negative psychotic symptoms, as measured by either of two standardized clinician administered tests, the Brief Psychiatric Rating Scale (BPRS), and the Positive and Negative Symptom Scale (PANSS).ResultsThe comparison of the different antipsychotics established the supremacy of ECT-augmented clozapine treatment against other typical and atypical antipsychotics. The Forest Plot revealed that the overall standard mean difference was 0.891 for non-clozapine studies and 1.504 for clozapine studies, at a 95% interval. Furthermore, the heterogeneity plots showed that while clozapine studies showed no significant heterogeneity, non-clozapine studies showed an I2 statistic value at 42.19%, suggesting moderate heterogeneity. Lastly, publication bias showed asymmetrical plots and significant values of Kendal's tau and Egger's rank test.ConclusionECT augmentation technique was found to be effective in the reduction of psychometric scale scores, and the resulting improvement was significant. Clozapine maintained its stance as the most effective treatment for Treatment-Resistant Schizophrenia, followed by flupenthixol.

Clozapine: An Updated Overview of Pharmacogenetic Biomarkers, Risks, and Safety—Particularities in the Context of COVID-19

“…In addition to clozapine, ECT is an effective treatment in resistant schizophrenia spectrum disorders [64,65]; ECT's practice still lacks consensual protocols. The first reported success in clozapine augmentation treatment by electroconvulsive therapy was first described in the early 1990s.…”

Clozapine. Pharmacodynamic Mechanisms, Potential Pharmacogenetic Biomarkers, and Risks in Schizophrenia. Particularities in the Context of Covid-19. An Updated Overview

“…Since then, this therapeutical combination has been used as the last line of treatment, with excellent results that show clozapine's superior efficacy when compared to other antipsychotics in combination with ECT. A metanalysis published in 2017 compared the effect of the combined treatment with Clozapine and ECT and other non-clozapine antipsychotics like flupenthixol, chlorpromazine, risperidone, sulpiride, olanzapine, and loxapine [63]. This paper analyzed 1179 patients from 23 studies, which reported antipsychotic treatment augmented with ECT.…”

Setting up an electroconvulsive therapy (ECT) Department in the Psychiatric Hospital “Dr. GH. Preda” of Sibiu

“…(2) The comparison of the different antipsychotics established the supremacy of ECTaugmented clozapine treatment against other typical and atypical antipsychotics. (15) The utility of ECT in neuroleptic malignant syndrome (NMS) is well recognised, despite the absence of randomised controlled data (2) (benefits up 90 % of cases). Particular care is required in the anaesthetic management of patients with NMS, as autonomic instability is a key feature.…”