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ECT and Schizophrenia
The following is taken from an email from Bob Lane,.
From: Bob Lane Subject: ECT
I posted short extracts from three books that discussed the role of ECT in treating schizophrenia. Here is a repeat of that post from Dec 23, 1996.
About a month ago there was some discussion about ECT and more recently a question was posed to everyone about treatment of catatonia. I have been meaning to send mail on these topics but this is the first opportunity that I have had. My reading suggests that these are related topics.
For those interested I have quotations from three sources:
1) E. Fuller Torrey, Surviving Schizophrenia, Third Edition:
Electroconvulsive therapy (ECT) has a modest but definite role to play in the treatment of schizophrenia despite the adverse publicity it has received. It is a favorite whipping boy for Scientologiests and antipsy-chiatry advocates and was even banned from use in Berkeley, California, in 1982 by a local referendum. In European countries it has been used more widely for the treatment of schizophrenia than in the United States.
Indications for use of ECT in schizophrenia were recently summarized in the New England Journal of Medicine as being "when the onset is acute and confusion and mood disturbance are present; and catatonia from almost any underlying cause." It may also be useful in some treatment-resistant cases, although it should be used in conjuction with an antipsychotic in such cases. Modern ECT is done using unilatural electrodes over the nondominant lobe to minimize memory loss. Some memory loss may nevertheless occur and is the major side effect of the procedure. Despite Scientologist claims to the contrary, there is no evidence that ECT causes any damage to the brain. Some patients respond to as few as 12 ECT treatments, whereas others need 20 or more. For individuals who respond well to ECT but rapidly relapse, it is possible to use monthly maintenance treatments. [p. 218]
My son has been a participant in schizophrenia research conducted by Sophia Vinogradov in San Francisco. She edited a book entitled:
in which Geoffrey K. Booth contributed a chapter that discusses ECT.
"Electroconvulsive therapy (ECT) has been used primarily in the treatment of life-threatening depression and, in fact, it works quite well for depressed patients. It is faster and actually safer in many cases than high doses of antidepressant drugs over a long period of time.
The track record for ECT in the treatment of schizophrenia is not nearly as impressive. It remains a biological treatment worthy of consideration in some clinical situations. Classic catatonia, for example, is responsive to ECT. Although this type of schizophrenia is relatively rare today, ECT can bring about a rapid cure of it waxy flexibility, mutism, and catatonic unresponsiveness.
Patients with schizoaffective disorders where depression is prominent also respond well to ECT. You might consider asking for a psychiatric consultation for electroconvulsive therapy when the following conditions apply:
1. Your patient won't eat and is losing significant amounts of weight.
2. Your patient had a very rapid and dramatic onset of the illness by has not responded to two different antipsychotic drugs in reasonably high doses.
3. Your patient is extremely autistic and shows mutism, rock behavior, stereotyped movements, and inattention to bladder and bowel hygiene.
4. Your patient perseverates constantly on one theme or shows severe obsessions and compulsions that interfere with his or her eating, sleeping, and other vegetative functions (for example, a psychotic patient who believes that her food is poisoned, talks about nothing else and loses weight; a psychotic patient who is washing his hands so often and roughly that his hands are bleeding). [pp. 162f]
3) Chapter 20 in Hirsch and Weinberger's Schizoprenia discusses ECT at length.
In this chapter R. B. Krueger and H. A. Sackeim discuss ECT in relation to 4 special populations: catatonia, lethal catatonia, schizoaffective disorder, and Neuroleptic Malignant Syndrome (NMS). I have deleted references to the literature and related discussions.
It has long been contended that presentation of catonic symptoms constitutes special indication for the use of ECT. Part of the difficulty in evaluating this claim is the recognition that catatonia may be manifested in a variety of psychiatric disorders or as a consequence of medical illness.....In our experience, ECT results in rapid and often dramatic improvement in specific catatonic features, such as mutism and motility disturbance, but more variable effects on core psychotic phenomena.
Special consideration should be given to the syndrome of lethal catatonia. This is a life-threatening condition, characterized by stupor or excitement, hyperthermia, clouded consciousness and autonomic dysregulation.....The literature on this syndrome, which consists solely of case series, suggests that neuroleptic treatment is of limited efficacy. Indeed, given the difficulty in distinguishing lethal catatonia from neuroleptic malignant syndrom (NMS), escalation of neuroleptic dosage may be counterproductive. In contrast, ECT, particularly when instituted prior to a comatose stage, appears to be effective.....
Expert groups, such as the APA Task Force on ECT, have suggested that this form of treatment is particularly valuable when schizophrenic patients present with prominent affective symptoms. Some of the early investigators found that mood disturbance was a predictor of positive ECT outcome in schizophrenic patients. This may not be specific to ECT as affective features may portend a better prognosis in schizophrnia, regardless of treatment.....
NMS shares clinical features with lethal catatonia and has been considered an iatrogenic form of lethal catatonia induced by exposure to neuroleptics.When the clinical community became cognizant of NMS, there was reluctance to treat these patients with ECT. This reluctance was hyperthermia, a familial syndrome provoked by exposure to general anaesthesia and depolarizing muscle relaxants, such as succinylcholine. However, NMS and malignant hypertheria have been shown to be unrelated syndromes. Indeed several reviews have documented that ECT is an effective treatment for NMS..... [pp. 525ff]
I hope that the quotes from these three sources help.