Combining ECT and clozapine in the treatment of clozapine-refractory schizophrenia and schizoaffective disorder – a pilot study

Abstract

<p><strong>Objective.</strong> Clozapine is the current gold standard treatment for severe treatment-refractory schizophrenia, but even so 40 - 70% of these patients will continue to experience disabling symptoms when treated with clozapine monotherapy. Current clinical practice at Stikland Hospital holds that known clozapine-refractory schizophrenia patients who relapse due to non-compliance are treated with an initial combination of clozapine and ECT (if able to consent) when readmitted. The purpose of this study was to evaluate the validity of this practice. <strong></strong></p><p><strong>Methods.</strong> Patients were divided into an ECT (EG) and non-ECT (CG) group. Clozapine was started and ECT administered as per protocol. Demographic data, psychiatric and medication history and data concerning adverse events were collected. Positive and Negative Symptom Scale (PANSS) scores were done at baseline and at days 21 and 42.<strong> </strong></p><p><strong>Results.</strong> At discharge, although numerically the average increase in clozapine dose was lower and the reduction in length of stay was greater in the EG, none of the variables measured were statistically significantly different between groups. More concomitants were also used in the EG. <strong></strong></p><p><strong>Conclusions.</strong> This pilot study represents the first controlled trial of ECT-clozapine bitherapy in a population with clozapine- refractory schizophrenia and schizoaffective disorder reported in the literature. The validity of our choice of current clinical practice in this population was not supported by our results. However, the study did provide us with preliminary evidence for the safety and efficacy of this combination. It would therefore be reasonable to continue to use this strategy in selected cases, at least until other clozapine-refractory treatment strategies become more available in our setting.</p>

Treatments for people living with schizophrenia in Sub‐Saharan Africa: an adapted realist review

“…In a similar study, Koen et al. () concluded that there was no advantage of combining ECT with clozapine therapy for treatment resistant schizophrenia.…”

Combined use of clozapine and ECT: a review

“…However, other studies have reported no difference in symptom reduction, when the combined treatment was compared with the clozapine-only group (35). Studies that have compared combination of clozapine and ECT with that of ECT and other psychotropics reported no difference in the response rate between the clozapine and non-clozapine groups (27).…”

“…However, occasional reports have used the combination concurrently (27,34,35). Although some of the reports have used rating scales such as the Positive and Negative symptom scale (PANSS) and Brief Psychiatric Rating scale (BPRS) to evaluate the response of the combined treatment, many authors have not relied on the standardised rating scales and have reported the outcome on the basis of the subjective outcome (25,28,(36)(37)(38).…”

“…35.7%) patients showed marked and sustained clinical improvement Five (35.7%) patients showed transient improvement followed by relapse (no mention of followup period) One (7.1%) patient had transient improvement followed by relapses and received maintenance ECT but experienced relapse on maintenance ECT Benatov et al…”

Clozapine-resistant schizophrenia – non pharmacological augmentation methods

“…Reports evaluating the effectiveness of such treatment in patients with schizophrenia mainly concern patients who have been resistant to clozapine [27][28][29][30]35]. However, occasional reports of simultaneous use of both methods have been made [29,36,37].…”