Shock therapy, a controversial practice conjuring frightening images of behavior control, still has a place in schizophrenia treatment, a newly updated research review shows.
Although the data confirmed that antipsychotic drugs are still the first choice for schizophrenia treatment, they also showed that electroconvulsive, or shock, therapy clearly works, and combining both treatments can accelerate benefits to some patients, the review finds.
Dr. Prathap Tharyan, head of psychiatry at Christian Medical College in Tamil Nadu, India, and colleagues analyzed 26 randomized controlled trials, involving 1,485 adult patients, 798 of whom were treated with shock therapy. Trials were conducted in India, the United States, Thailand, Canada, Hungary and Nigeria.
The review appears in the most recent issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.
“ The most significant finding is that ECT combined with antipsychotics is more effective than antipsychotics alone in producing rapid clinical improvement in people with schizophrenia,” Tharyan said. Rapid improvement of symptoms is potentially lifesaving, for instance, when a person with schizophrenia is suicidal.
The review also refutes a public perception that ECT is dangerous and causes brain damage and suggests that for some patients the side effects of shock therapy may be more tolerable than those of antipsychotic drugs.
ECT induces a seizure with electric stimulus shock, given by electrodes attached to the scalp. Seizures last from 25 to 30 seconds. Patients are given short-acting anesthetics and muscle relaxants to decrease anxiety and protect them from injury during muscle contractions. Patients generally receive ECT two to three times a week, usually for a total of eight to 12 treatments in a series.
The American Psychiatric Association supports use of ECT only to treat severe, disabling mental disorders. However, the National Institute for Clinical Excellence in the United Kingdom does not recommend general use of ECT for schizophrenia, although it may be indicated for catatonia.
About 2.2 million American adults, or 1.1 percent of the adult population, have schizophrenia, according to 2001 figures from the National Institute of Mental Health. Twenty percent of people with schizophrenia fail to respond to drug therapy alone.
Researchers used sophisticated statistical methods to reach conclusions based on data pooled from individual, randomized studies.
Studies used a variety of tests to measure psychiatric symptoms and psychological, social and occupational functioning.
Ten trials compared shock therapy directly with drug therapy. “When ECT given without antipsychotics is directly compared to treatment with antipsychotics alone … results strongly favor the medication group,” reviewers found. They also found “very limited data” suggesting that people treated with ECT are less likely to relapse.
Further, one trial indicated that the combination of ECT and antipsychotics offered significant advantages that were maintained beyond the short term.
Several trials assessed cognitive side effects, such as memory impairment. Others measured side effects often seen with antipsychotic drugs, such as tremor, slurred speech, inability to keep still, anxiety and paranoia. Some data indicated that these side effects were less severe with ECT than with antipsychotic drugs.
A small trial found more impairment with ECT and antipsychotics combined than antipsychotics alone. “However,” authors noted, “when re-tested nine weeks later, memory function had improved in both groups and no significant differences were detected.”
A very small trial showed a decline in visual memory after ECT compared with those who were given anesthesia and nothing else.
Dr. David Spiegel, professor of psychiatry at Stanford University School of Medicine, has used ECT to treat patients with depression but views its use in schizophrenia as a last resort.
“I would worry that in some of the studies, patients may not have been on an aggressive enough drug schedule to treat early symptoms rapidly,” Spiegel says. “You would have to include only studies where drug control was optimal.
“Lots of people — especially many with delusions — are still uncomfortable with ECT, although it’s terrific for depression,” Spiegel says.
ECT came into use in the late 1930s, but it waned in developed nations with the introduction of antipsychotics and antidepressants in the 1950s.
Tharyan says that in countries with few state-funded social services, ECT can be useful as the more rapid treatment because the impact of long-running schizophrenia can cause both patients and family caregivers to stop working. ECT is more available and less expensive than antipsychotics in many developing areas.