Impact of medications, mood state, and electrode placement on ECT outcomes in treatment-refractory psychosis

Nicholas J Ainsworth; A Michelle Avina-Galindo; Randall F White; Denghuang Zhan; Elizabeth C Gregory; William G Honer; Fidel Vila-Rodriguez

doi:10.1016/j.brs.2022.08.012

Impact of medications, mood state, and electrode placement on ECT outcomes in treatment-refractory psychosis

Brain Stimul. 2022 Sep-Oct;15(5):1184-1191. doi: 10.1016/j.brs.2022.08.012. Epub 2022 Aug 24.

Authors

Nicholas J Ainsworth¹, A Michelle Avina-Galindo², Randall F White³, Denghuang Zhan⁴, Elizabeth C Gregory¹, William G Honer⁵, Fidel Vila-Rodriguez⁶

Affiliations

¹ Non-Invasive Neurostimulation Therapies Laboratory, University of British Columbia, Vancouver, BC, Canada; Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada.
² Non-Invasive Neurostimulation Therapies Laboratory, University of British Columbia, Vancouver, BC, Canada.
³ Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada; British Columbia Psychosis Program, Vancouver, BC, Canada.
⁴ Non-Invasive Neurostimulation Therapies Laboratory, University of British Columbia, Vancouver, BC, Canada; Centre for Health Evaluation and Outcomes Sciences, St Paul's Hospital, Vancouver, BC, Canada.
⁵ Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada; British Columbia Psychosis Program, Vancouver, BC, Canada; British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, BC, Canada.
⁶ Non-Invasive Neurostimulation Therapies Laboratory, University of British Columbia, Vancouver, BC, Canada; Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada. Electronic address: fidel.vilarodriguez@ubc.ca.

PMID: 36028155
DOI: 10.1016/j.brs.2022.08.012

Abstract

Background: Treatment-refractory psychosis (TRP) is a significant clinical challenge. While clozapine is frequently effective, alternate or augmentation strategies are often necessary. Evidence supports effectiveness of electroconvulsive therapy (ECT), but questions remain about optimal treatment parameters and impacts of concomitant pharmacotherapy.

Objective: /Hypothesis: To analyze the impact of clozapine, anticonvulsant medication, mood state, and ECT electrode placement on outcomes in TRP. We hypothesized that ECT would lead to greater reduction in positive symptoms, particularly in patients receiving clozapine.

Methods: Retrospective study in a tertiary TRP program. The Positive and Negative Syndrome Scale (PANSS) was used for clinical outcomes, with positive subscore as primary outcome. Clinical and ECT data were analyzed using a linear modelling approach, controlling for relevant covariates.

Results: A total of 309 patients were included. ECT plus clozapine associated with greater improvement in positive, general, and total symptoms than ECT alone. ECT associated with greater improvement in negative symptoms in depressed patients. Bifrontal placement was mostly equivalent to bitemporal, with greater reduction of positive symptoms in patients receiving clozapine, and associated with lower electrical dose in patients on anticonvulsants. Clozapine increased seizure duration, while anticonvulsants decreased it. Anticonvulsant use in ECT patients associated with equivalent to slightly improved symptom reduction.

Conclusions: ECT's benefit in TRP may be greatest in patients receiving clozapine. ECT can improve negative symptoms in depressed TRP patients. Bifrontal placement is effective in TRP. Clozapine and anticonvulsants have opposite effects on seizure duration, but anticonvulsants may not adversely affect clinical outcomes of ECT for TRP.

Keywords: Anticonvulsant; Clozapine; Electroconvulsive therapy; Schizophrenia; Treatment-refractory psychosis.

MeSH terms

Anticonvulsants / therapeutic use
Antipsychotic Agents* / therapeutic use
Clozapine* / therapeutic use
Electroconvulsive Therapy* / adverse effects
Electrodes
Humans
Psychotic Disorders* / therapy
Retrospective Studies
Schizophrenia* / therapy
Seizures
Treatment Outcome

Substances

Anticonvulsants
Antipsychotic Agents
Clozapine