Chitra Malur

Electroconvulsive therapy augmentation in clozapine-resistant schizophrenia: a prospective, randomized study

OBJECTIVE Up to 70% of patients with treatment-resistant schizophrenia do not respond to clozapine. Pharmacological augmentation to clozapine has been studied with unimpressive results. The authors examined the use of ECT as an augmentation to clozapine for treatment-refractory schizophrenia. METHOD In a randomized single-blind 8-week study, patients with clozapine-resistant schizophrenia were assigned to treatment as usual (clozapine group) or a course of bilateral ECT plus clozapine (ECT plus clozapine group). Nonresponders from the clozapine group received an 8-week open trial of ECT (crossover phase). ECT was performed three times per week for the first 4 weeks and twice weekly for the last 4 weeks. Clozapine dosages remained constant. Response was defined as ≥40% reduction in symptoms based on the psychotic symptom subscale of the Brief Psychiatric Rating Scale, a Clinical Global Impressions (CGI)-severity rating <3, and a CGI-improvement rating ≤2. RESULTS The intent-to-treat sample included 39 participants (ECT plus clozapine group, N=20; clozapine group, N=19). All 19 patients from the clozapine group received ECT in the crossover phase. Fifty percent of the ECT plus clozapine patients met the response criterion. None of the patients in the clozapine group met the criterion. In the crossover phase, response was 47%. There were no discernible differences between groups on global cognition. Two patients required the postponement of an ECT session because of mild confusion. CONCLUSIONS The augmentation of clozapine with ECT is a safe and effective treatment option. Further research is required to determine the persistence of the improvement and the potential need for maintenance treatments.

ECT for prolonged catatonia.

Objective and Background Electroconvulsive therapy (ECT) is highly effective for acute catatonia but its use in prolonged catatonia is not well established. We report three cases of prolonged catatonia with medical complications or comorbidities treated by ECT. Method Case reports. Results A 24 year-old woman developed fever and autonomic instability after parenteral neuroleptics. Catatonia and autonomic signs persisted for 14 weeks. After minimal improvement from lorazepam, 15 bilateral ECTs led to resolution. A 26-year-old woman with a history of lupus erythematosus, complicated by lupus cerebritis with lesions in the cortex and basal ganglia and a communicating hydrocephalus, was catatonic for 9 weeks. Lorazepam produced marginal improvement. A series of 14 bilateral ECTs led to improved mobility, speech, and interaction, but the response was less robust than Case 1. A 40-year-old man with mental retardation and intermittent psychosis developed severe neuroleptic malignant syndrome and remained catatonic for 4 months. After lorazepam produced minimal improvement, his catatonia resolved with 20 bilateral ECTs. Conclusions ECT may improve prolonged catatonia with complex medical comorbidities, but may require many treatment sessions. Gross cerebral pathology may predict a less robust response. As for acute catatonia, ECT may resolve prolonged catatonia after benzodiazepines have failed.

Emergence of catatonia during ECT.

Emergence of catatonia during electroconvulsive therapy (ECT) is unexpected, as catatonia responds well to ECT. We report four cases with onset of catatonia during ECT. Four inpatients with affective disorders (three without prior catatonia) developed catatonia by Bush-Francis criteria during a course of ECT. All four patients had been taking benzodiazepines, which were stopped 5-15 days before ECT. Two became catatonic after ECT no. 4, one after ECT no. 1, and one after ECT no. 10. The episodes of catatonia resolved promptly with the resumption of benzodiazepines. Two patients completed a course of ECT, whereas two received neuroleptics and/or antidepressants without further ECT. All showed improvements in their affective and psychotic symptoms. The cases illustrate the appearance of catatonia during a course of ECT and suggest recent cessation of benzodiazepines as a risk factor. Benzodiazepines relieve the catatonia, and ECT may be continued.

Effect of Probationary Accreditation on Recruitment of Psychiatry Residents

To the Editor: Although there are clear reasons why programs do not want to advertise probationary accreditation, programs that have been on probation can offer valuable insights as there is nothing in the medical education literature on this topic. When our training program received an accreditation status of probationary accreditation, one of our concerns was whether there would be an adverse effect on recruitment. As a precaution, we doubled the number of candidates that we interviewed. However, there was no literature examining the effects of probation on recruitment to justify the increased investment of resources. We distributed an online survey to candidates to understand how the accreditation status affected their ranking decisions and their fears about joining a program on probation through Research Electronic Data Capture (REDCap), hosted at the Tufts Clinical and Translational Science Institute. The anonymous survey had no link between the response and the email address or any other identifier. St. Elizabeth’s Medical Center determined that the study was exempt from IRB oversight. The completion rate was 61% for candidates who interviewed with the program (n=142) and 13 % for those not invited for an interview (n=962). Only 27 % of candidates who interviewed with the program indicated that they ranked the program lower than they would have if it had not been on probation. In contrast, 42 % of the candidates who were not invited to interview indicated that they would have ranked the program lower. An important caveat, however, is that accreditation status changed to full accreditation a few days before the candidates needed to finalize their rank order lists. The majority of candidates acknowledged that resident happiness is more important than full accreditation. Among candidates who interviewed, 71 % indicated that they would rather go to a program on probation with happy residents as opposed to a fully accredited program with unhappy residents, whereas 7 % preferred full accreditation with unhappy residents and 22 % were uncertain. Among those who were not invited to interview, 53 % preferred probation with happy residents, 21 % preferred full accreditation with unhappy residents, and 27 % were uncertain. The primary concern endorsed by the majority of candidates (58 % of respondents who interviewed with the program and 76 % of respondents who were not selected to interview) was fear that the program would close before their graduation. Of those who interviewed, 15 % were concerned primarily about the quality of the educational experience, 12 % about the quality of the resources available to residents, and 12 % about the prestige of the program. Among respondents who were not selected to interview with the program, the percentages were 13, 0, and 6 %, respectively. The class that entered shortly after the program was placed on probation also worried that the program would be closed during their training, but their fears were addressed through meetings with the department chair, program director, designated institutional official, and director of medical education. Although information about programs on probation is publically available on the website of the Accreditation Council for Graduate Medical Education (ACGME), only 17 % of the respondents who interviewed with the program learned about the program’s status through the website. The majority (76 %) learned it from the interview invitation, where it was disclosed * Tara L. Lauriat tara.lauriat@steward.org