May 01, 2005

Recent Cochrane Reviews

Recent Cochrane Reviews With Schizophrenia Content

Cochrane reviews are considered by many to be the gold standard in systematic literature reviews. The reviews are done rigorously and include all sources on a particular subject with strict criteria for which studies can be considered “good” evidence versus “weak” evidence. Studies sponsored by pharmaceutical companies are considered in the context of their sponsorship for example. By applying rules to their inclusion of particular studies, they are able to group the remaining studies and come up with solid recommendations for evidence based medicine.

1. ECT and schizophrenia – ECT (electroconvulsive therapy) is typically thought of for its use in intractable depression, however a recently published review looks at the evidence for its usage in schizophrenia. ECT is a technique that induces a seizure by sending electrical current that overwhelms the neurons in the brain. It is considered very effective in treatment for depression, however has side effects and requires anesthesia that make its use prohibitive at times. The most common side effect is short term memory loss, though the memory is usually recovered. There is no solid evidence of long term brain damage from ECT. According to an APA task force, ECT can be useful in schizophrenia when there is an “abrupt or recent onset, severe catatonic stupor, catatonic excitement, positive previous response to ECT.”

In the review, the authors looked at 26 different trials (50 reports). When looking at the best studies (double-blind, placebo-controlled, randomized and controlled) they found that overall ECT had a benefit compared to a sham treatment. There was weaker evidence that relapses were less frequent after ECT and that people were released from the hospital more quickly if they received ECT compared to a sham treatment. However, it was noted that the long term benefits of ECT were not known and not thought to be the same as the short term effects.

When ECT was compared with antipsychotic treatment directly, medication was considered to be superior. This maintains current practice with medication clearly used before one resorts to ECT and that ECT by itself is not a sufficient treatment for schizophrenia. However, it was seen that ECT, when combined with antipsychotic medication showed a greater improvement in symptoms, however there were greater memory related side effects. When ECT was used in a more long term setting, it also showed a benefit compared to just medication treatment.

Overall, ECT is a treatment that is used infrequently and is considered a last resort generally. However, the evidence shows that perhaps it does have role, particularly when a rapid improvement is needed or when symptoms are especially severe. Ultimately though, it is not entirely clear what the benefit is in the long term and also the side effects of long term use. Many of the studies used to come up with the review were old and while some current research is being done, there is much to be discovered about the mechanism and side effects of ECT. While some is now known about ECT, there is still a lot more research that would need to happen before it could be considered efficacious and safe for more widespread use.

2. Music Therapy and schizophrenia

Music therapy is a type of psychotherapy in which the patient is encouraged to utilize music to improve interpersonal and communication skills in ways that regular dialogue is limited. Forms of music therapy generally are based around cognitive/behavioral, humanistic or psychoanalytic frameworks or a mixture of approaches. There are usually both active and receptive parts of the therapy, meaning that at times music is listened to and at other times there is the use of musical improvisation or creation. There have not been many studies on music therapy and schizophrenia, but the Cochrane review looked at the data available for a recent review.

There were 4 studies included in the review. These studies looked at short term benefits of music therapy when used in addition to more conventional pharmaceutical treatments. The authors combined the results of these 4 studies in a “meta-analysis” meaning that the studies were similar enough that the data could be combined and form a larger sample. The number of sessions used in these studies varied from 7 to 75 and the length of time studied ranged up to 3 months duration.

The results were encouraging. In one study, it was shown that the global state in the short term was frequently improved. Using a statistic called “number needed to treat (NNT)” it was described that to show an improvement in one patient, you only needed to put two patients through the therapy. (This compares with NNT in many situations of several hundred patients needed to be given a treatment in order to notice benefits in one person.) It was shown that the number of sessions had a direct impact on the success of the treatment with more sessions being better. It was also seen that active participation was better than a more passive approach to treatment. However, the length of treatment in theses studies was short and the benefit in the long term was unknown.

Tharyan P, Adams C.
Electroconvulsive therapy for schizophrenia.
Cochrane Database Syst Rev. 2005 Apr 18;(2):CD000076.

Gold C, Heldal T, Dahle T, Wigram T.
Music therapy for schizophrenia or schizophrenia-like illnesses.
Cochrane Database Syst Rev. 2005 Apr 18;(2):CD004025.

Click here for article 1 on PubMed

Click here for article 2 on PubMed


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