Chapter 2: 2.1. - Indications for Use of ECT - The Utility of Monotherapy with ECT

Written by Juli Lawrence

The utility of monotherapy with ECT or antipsychotic medication was compared in a variety of retrospective (DeWet 1957; Borowitz 1959; Ayres 1960; Rohde and Sargant 1961) and prospective (Baker et al. 1958, 1960b; Langsley et al. 1959; King 1960; Ray 1962; Childers 1964; May and Tuma 1965, May 1968; May et al. 1976,1981; Bagadia et al. 1970; Murrillo and Exner 1973a, 1973b; Exner and Murrillo 1973, 1977; Bagadia et al. 1983) studies of patients with schizophrenia. In general, short-term clinical outcome in schizophrenia with antipsychotic medication was found to be equivalent or superior to that of ECT, although there were exceptions.

(Murrillo and Exner 1973a). However, a consistent theme in this literature was the suggestion that patients with schizophrenia who had received ECT had superior long-term outcome compared with medication groups (Baker et al. 1958; Ayres 1960; May et al. 1976, 1981; Exner and Murrillo 1977). This research was conducted in an era when the importance of continuation and maintenance treatment was not appreciated and none of the studies controlled the treatment received following resolution of the schizophrenic episode. Nonetheless, the possibility that ECT may have long-term beneficial effects in schizophrenia merits attention.

A variety of prospective studies have compared the efficacy of combination treatment using ECT and antipsychotic medication with monotherapy with ECT or antipsychotic medication (Ray 1962; Childers 1964; Smith et al. 1967; Janakiramaiah et al. 1982; Small et al. 1982; Ungvari and Petho 1982; Abraham and Kulhara 1987; Das et al. 1991). Relatively few of these studies involved random assignment and blind outcome assessment. Nonetheless, in each of the three studies in which ECT alone was compared with ECT combined with an antipsychotic, medication there was evidence that the combination was more effective (Ray 1962; Childers 1964; Small et al. 1982). With the exception of Janakiramaiah et al (1982), all studies that compared the combination treatment with antipsychotic medication monotherapy found the combination treatment to be more effective (Ray 1962; Childers, 1964: Smith et al. 1967; Small et al. 1982: Ungvari and Petho 1982; Abraham and Kulhara 1987; Das et al. 1991). This pattern held despite the dosage of the antipsychotic medication often being lower when combined with ECT. The few findings on the persistence of benefit suggested that there was a reduced rate of relapse in patients who had received the combination of ECT and antipsychotic medication as acute phase treatment. A new study has also found that combination ECT and antipsychotic medication is more effective as a continuation therapy than either treatment alone in patients with medication-resistant schizophrenia who respond to the combination treatment in the acute phase (Chanpattana et al. in press). These results support the recommendation that in the treatment of patients with schizophrenia and possibly other psychotic conditions the combination of ECT and antipsychotic medication may be preferable to the use of ECT alone.

In current practice ECT is rarely used as a first-line treatment for patients with schizophrenia. Most commonly, ECT is considered in patients with schizophrenia only after unsuccessful treatment with antipsychotic medication. Thus, the key clinical issue concerns the efficacy of ECT in medication-resistant schizophrenic patients.

There has yet to be a prospective, blinded study in which patients with medication-resistant schizophrenia are randomized to continued treatment with antipsychotic medication or to ECT (either alone or in combination with antipsychotic medication). Information on this issue comes from naturalistic case series (Childers and Therrien 1961; Rahman 1968; Lewis 1982; Friedel 1986; Gujavarty et al, 1987; Konig and Glatter-Gotz 1990; Milstein et al. 1990; Sajatovi and Meltzer 1993; Chanpattana et al. in press). This work suggests that a substantial number of patients with medication-resistant schizophrenia benefit when treated with combination ECT and antipsychotic medication. The safe and effective use of ECT has been reported when it has been administered in combination with traditional antipsychotic medications (Friedel 1986; Gujavarty et al. 1987; Sajatovi and Meltzer 1993) or those with atypical properties, particularly clozapine (Masiar and Johns 1991; Klapheke 1991a. 1993; Landy 1991; Safferman and Munne 1992; Frankenburg et al. 1992; Cardwell and Nakai, 1995; Farah et al. 1995; Benatov et al. 1996). While some practitioners have been concerned that clozapine may increase the likelihood of prolonged or tardive seizures when combined with ECT (Bloch et al. 1996), such adverse events appear to be rare.

Prediction of response. Since the earliest research, the clinical feature most strongly associated with the therapeutic outcome of ECT in patients with schizophrenia has been the duration of illness. Patients with acute onset of symptoms (i.e., psychotic exacerbations) and shorter illness duration are more likely to benefit from ECT than patients with persistent, unremitting symptomatology (Cheney & Drewry 1938; Ross and Malzberg 1939; Zeifert 1941; Kalinowsky 1943; Lowinger and Huddelson 1945; Danziger and Kindwall 1946; Herzberg 1954; Landmark et al. 1987; Dodwell and Goldberg 1989). Less consistently, preoccupation with delusions and hallucinations (Landmark et al. 1987), fewer schizoid and paranoid premorbid personality traits (Wittman 1941; Dodwell and Goldberg 1989), and the presence of catatonic symptoms (Kalinowsky and Worthing 19431; Hamilton and Wall 1948; Ellison and Hamilton 1949; Wells, 1973; Pataki et al. 1992) have been linked to positive therapeutic effects. In general, the features that have been associated with the clinical outcome of ECT in patients with schizophrenia overlap substantially with features that predict outcome with pharmacotherapy (Leff and Wing 1971; World Health Organization 1979; Watt et al. 1983). While patients with unremitting, chronic schizophrenia are the least likely to respond, it has also been argued that such patients should not be denied a trial of ECT (Fink and Sackeim 1996). The probability of significant improvement with ECT may be low in such patients, but alternative therapeutic options may be even more limited, and a small minority of patients with chronic schizophrenia may show dramatic improvement following ECT.

ECT may also be considered in the treatment of patients with schizoaffective or schizophreniform disorder (Tsuang, et al. 1979; Pope et al. 1980; Ries et al. 1981; Black et al. 1987c). The presence of perplexity or confusion in patients with schizoaffective disorder may be predictive of positive clinical outcome (Perris 1974; Dempsy et al. 1975; Dodwell and Goldberg 1989). Many practitioners believe that the manifestation of affective symptoms in patients with schizophrenia is predictive of positive clinical outcome. However, the evidence supporting this view is inconsistent (Folstein et al. 1973; Wells 1973, Dodwell and Goldberg 1989).

2.4. Other Diagnostic Indications

ECT has been used successfully in some other conditions, although this utilization has been rare in recent years (American Psychiatric Association 1978, 1990, Thompson et al. 1994). Much of this usage has been reported as case material, and typically reflects the administration of ECT only after other treatment options have been exhausted or when the patient presents with life-threatening symptomatology. Because of the absence of controlled studies, which would, in any event, be difficult to carry out given the low utilization rates, any such referrals for ECT should be well substantiated in the clinical record. The use of psychiatric or medical consultation by individuals experienced in the management of the specific condition may be a useful component of the evaluation process.