Revisiting the role of electroconvulsive therapy in schizophrenia: Where are we now?

Abstract

Objective: The purpose of this opinion article is to review the recent evidence base in relation to the role of electroconvulsive therapy (ECT) in the management of patients with schizophrenia. Specifically, we explore the efficacy and safety of ECT. Furthermore, consideration is given to the profile of patients who benefit most from ECT, the role of maintenance ECT and what happens when ECT is not given. Conclusion: Our brief review of the evidence suggests that clinical practice in developing countries has not kept up with the growing literature supporting ECT use in schizophrenia. As such, we advocate that ECT should not be a treatment of last resort. Rather, it should be considered more readily as an add-on therapy when there has been a poor response to antipsychotic medications or concerns exist about side effects. Further research is needed into the efficacy of maintenance ECT.

When to consider electroconvulsive therapy (ECT)

“…Recent literature has focused on ECT as an addon treatment for patients with treatment-resistant schizophrenia, including clozapine-resistant patients (28,29). 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 (30)(31)(32)(33)(34)(35)(36), the totality of the evidence has been inadequate to convince either the US FDA (18) 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 mediumterm 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' (37).…”

Systematic Review of the Neural Effect of Electroconvulsive Therapy in Patients with Schizophrenia: Hippocampus and Insula as the Key Regions of Modulation

“…24 Considering the prevalence and rather striking socioeconomic consequences of TRS, clinicians have argued that ECT should not be used as the 'last resort' and that it should be increasingly applied to patients with schizophrenia. 9,25 Despite this context of robust effectiveness, the underlying mechanism of action of ECT has largely remained elusive. Historically, the generalized seizure hypothesis, changes in neurotransmitters and neuroendocrine function hypothesis, and the neurotrophic hypothesis has been postulated as working models of ECT.…”

“…A large volume of clinical research literature and systematic reviews along with an increasing number of treatment guidelines support the addition of ECT to antipsychotic agent regimens [ 15 - 23 ], including a recent review from the Cochrane systematic reviews [ 24 ]. Considering the prevalence and rather striking socioeconomic consequences of TRS, clinicians have argued that ECT should not be used as the ‘last resort’ and that it should be increasingly applied to patients with schizophrenia [ 9 , 25 ].…”

Adjunctive Magnetic Seizure Therapy for Schizophrenia: A Systematic Review

“…Despite advances in psychopharmacologic therapy, nearly 50% of schizophrenia patients do not respond to therapy with antipsychotics (5)(6)(7). Consequently, non-pharmacological therapies, such as augmentation strategies, have been widely used for schizophrenia in clinical practice, with neuromodulation techniques being particularly common (8), including electroconvulsive therapy (ECT) (9)(10)(11), repetitive transcranial magnetic stimulation (rTMS) (12), deep brain stimulation (DBS) (13,14), non-convulsive electrotherapy (15,16), transcranial direct current stimulation (tDCS) (17)(18)(19), and magnetic seizure therapy (MST) (20,21).…”