Volume 7 Issue 5 May, 2017
Treatment Resistant Schizophrenia (TRS) can be understood in simple terms when patient continues to have significant symptoms that impede him in returning to functioning decently despite an adequate trial with at least 2 types of medication. There are elaborate definitions and criteria which describe resistance in detail like Kane’s criteria. Prevalence varies anywhere between 5 – 60% but on an average, as high as 1 out of 5 patients diagnosed with schizophrenia may have resistance to medication when less restrictive criteria are applied. Clozapine is the drug of choice for 30 – 50% patients of schizophrenia who are treatment resistant. However, about 30% are resistant even to clozapine also and many others have side effects leading to discontinuation. An urgent unmet need is to look for other treatment modalities for these patients who are among the most severely disabled. A huge barrier to improvement is that the clinicians sometimes feel nihilistic while treating patients with resistance. However, even small symptomatic improvements among these patients can lead to positive impact on patient’s behavior and the burden of caregiving faced by the family members. Electroconvulsive Therapy (ECT) is the most promising in this regard. Unfortunately, use of ECT has declined in recent past because of stigma and negative attitudes.
Electroconvulsive therapy remains one of the most effective and safest modalities for patients with treatment resistant schizophrenia including clozapine resistant schizophrenia. It is recommended for this indication by almost all the treatment guidelines world over. A meta-analysis published in 2016 found that the combination of ECT with antipsychotics other than clozapine was superior in efficacy to antipsychotic mono-therapy. Only side effects reported were headache and memory impairment which were mild, transient and well tolerable. A systematic review published in 2016 concluded that ECT may be an effective and safe augmentation strategy in clozapine resistant schizophrenia. Studies using continuation and maintenance ECT have also shown that ECT is effective. However, these studies are too few and limited to draw any conclusions. Encouragingly, ECT improves negative symptoms of schizophrenia which have traditionally been considered resistant to treatments. While the optimal number of ECT sessions for schizophrenia remains unclear, 12 to 20 sessions have been shown to be adequate. The author studied efficacy of ECT in 30 treatment resistant patients including 12 with clozapine resistance. ECT improved psychopathology and quality of life in short term. Though the improvement in positive symptoms was more pronounced, negative symptoms also improved. However, the improvement was not sustained after discontinuing ECT. 10 years naturalistic course of patients who were clozapine resistant shows that their prognosis remains poor, thus highlighting the need to assess efficacy of continuation ECT or other therapies for these patients. Large, well designed, multicenter trials are required to unequivocally establish the effectiveness of continuation and maintenance ECT in treatment resistant schizophrenia so that this most effective and safe treatment modality is not lost to history.
At the bottom line, ECT remains an underutilized mode of therapy because of various factors. If the barriers are effectively overcome, it can be a very useful mode of therapy in TRS.
Dr. Rohit Garg, Assistant Professor of Psychiatry, Govt. Medical College and Rajindra Hospital, Patiala, Punjab
