Abstract
John Stevens, Peter Cheung, Tim Lambert, Melbourne, Australia:
The role of electroconvulsive therapy (ECT) is recognized in acute schizophrenia, and as an alternative to antipsychotics in patients with treatment-resistant schizophrenia [1]. However, the use of maintenance electroconvulsive therapy (M-ECT) is less well defined. Our Index Medicus/Medline search found only 12 reports of M-ECT in schizophrenia; only six of them specifically describe its use in schizophrenia [2], and only two are systematic research studies.
One study compared continuation electroconvulsive therapy (C-ECT) alone, with combination C-ECT and flupenthixol, and flupenthixol alone [2]. In this study, a significant relapse rate of 93% was noted with the use of either flupenthixol or C-ECT alone compared with only a 40% relapse rate following combination of C-ECT and flupenthixol. It should be noted that C-ECT was only given weekly for 4 weeks, and then bi-weekly for 5 months (total 14 C-ECT treatments), which may explain the high rate of relapse with C-ECT.
The other study was a retrospective study with a mixed sample [3]. However, those with a diagnosis of schizophrenia alone (three patients) received a longer course of M-ECT than patients in the previous study [2], in the order of 35–88 ECT treatments. The three patients were reported to have made significant improvement in the areas of level of functioning, discharge after prolonged hospitalization or reduction in aggression. We would like to report a patient who has required ongoing ECT treatment to avert deterioration of his mental state.
Mr L was a 50-year-old, separated man on a disability support pension living in supported accommodation. He had a 34-year history of chronic, paranoid, treatment- resistant schizophrenia with significant history of violence. He was first diagnosed at age 16, and required multiple prolonged admissions during his late teens and first 10 years of his adult life. He was reasonably stable between the ages of 28 and 38 with regular fluphenazine decanoate. However, following the transfer of his care to his general practitioner, he missed his depot medication and deteriorated rapidly, presenting with acute psychotic symptoms, disinhibition, verbal and physical aggression.
Over the next 6 months, he was admitted on five occasions to acute psychiatric units. Multiple agents including atypical antipsychotics in combination with depot antipsychotics were utilized with virtually no response. However, he did respond satisfactorily, albeit briefly, to short courses of ECT (usually 5–6 treatments) with disappearance of psychotic symptoms and physical aggression. The latter were important target symptoms as there was considerable concern over the potential for violence in this situation of manifest treatment resistance.
During his last admission, Mr L was transferred to a secure extended care ward with the aim of commencing him on clozapine. He remained there for the next 12 months. Unfortunately, he developed clozapineinduced neutropenia and clozapine was ceased. The patient, in addition to his already established treatmentresistant schizophrenia, then developed a super-sensitivitylike exacerbation of his psychosis on withdrawal of the clozapine. Over this period, he received regular short courses of ECT, but deteriorated rapidly each time upon cessation. Hence, he was prescribed M-ECT, initially weekly. He suffered from confusion (for a couple of days after ECT) and short-term memory impairment, but no other side-effects of the M-ECT.
Mr L was successfully discharged after receiving 42 treatments. He lives alone with intensive case management, and receives M-ECT 4-weekly (66 treatments to date). His improvement has been sustained. He no longer has confusion or memory impairment.
In conclusion, M-ECT has substantially improved Mr L's function and independence. Questions are how long to continue M-ECT and at what frequency? Mr L himself is keen to have ECT treatment terminated.