Electroconvulsive therapy for schizophrenia

 

Abstract

Background

Electroconvulsive therapy (ECT) involves the induction of a seizure for therapeutic purposes by the administration of a variable frequency electrical stimulus shock via electrodes applied to the scalp. The effects of its use in people with schizophrenia are unclear.

Objectives

To determine whether electroconvulsive therapy (ECT) results in clinically meaningful benefit with regard to global improvement, hospitalisation, changes in mental state, behaviour and functioning for people with schizophrenia, and to determine whether variations in the practical administration of ECT influences outcome.

Search methods

We undertook electronic searches of Biological Abstracts (1982-1996), EMBASE (1980-1996), MEDLINE (1966-2004), PsycLIT (1974-1996),SCISEARCH (1996) and the Cochrane Schizophrenia Group's Register (July 2004). We also inspected the references of all identified studies and contacted relevant authors.

Selection criteria

We included all randomised controlled clinical trials that compared ECT with placebo, 'sham ECT', non-pharmacological interventions and antipsychotics and different schedules and methods of administration of ECT for people with schizophrenia, schizoaffective disorder or chronic mental disorder.

Data collection and analysis

Working independently, we selected and critically appraised studies, extracted data and analysed on an intention-to-treat basis. Where possible and appropriate we calculated risk ratios (RR) and their 95% confidence intervals (CI) with the number needed to treat (NNT). For continuous data Weighted Mean Differences (WMD) were calculated. We presented scale data for only those tools that had attained pre-specified levels of quality. We also undertook tests for heterogeneity and publication bias.

Main results

This review includes 26 trials with 50 reports. When ECT is compared with placebo or sham ECT, more people improved in the real ECT group (n=392, 10 RCTs, RR 0.76 random CI 0.59 to 0.98, NNT 6 CI 4 to 12) and though data were heterogeneous (chi-square 17.49 df=9 P=0.04), its impact on variability of data was not substantial (I-squared 48.5%). There was a suggestion that ECT resulted in less relapses in the short term than sham ECT (n=47, 2 RCTs, RR fixed 0.26 CI 0.03 to 2.2), and a greater likelihood of being discharged from hospital (n=98, 1 RCT, RR fixed 0.59, CI 0.34 to 1.01). There is no evidence that this early advantage for ECT is maintained over the medium to long term. People treated with ECT did not drop out of treatment earlier than those treated with sham ECT (n=495, 14 RCTs, RR fixed 0.71 CI 0.33 to 1.52, I-squared 0%). Very limited data indicated that visual memory might decline after ECT compared with sham ECT (n=24, 1 RCT, WMD -14.0 CI -23 to -5); the results of verbal memory tests were equivocal.

When ECT is directly compared with antipsychotic drug treatments (total n=443, 10 RCTs) results favour the medication group (n=175, 3 RCTs, RR fixed 'not improved at the end of ECT course' 2.18 CI 1.31 to 3.63). Limited evidence suggests that ECT combined with antipsychotic drugs results in greater improvement in mental state (n= 40, 1 RCT, WMD, Brief Psychiatric Rating Scale -3.9 CI - 2.28 to -5.52) than with antipsychotic drugs alone. One small study suggested more memory impairment after a course of ECT combined with antipsychotics than with antipsychotics alone (n=20, MD serial numbers and picture recall -4.90 CI -0.78 to -9.02), though this proved transient. When continuation ECT was added to antipsychotic drugs, the combination was superior to the use of antipsychotics alone (n=30, WMD Global Assessment of Functioning 19.06 CI 9.65 to 28.47), or CECT alone (n=30, WMD -20.30 CI -11.48 to -29.12).

Unilateral and bilateral ECT were equally effective in terms of global improvement (n=78, 2 RCTs, RR fixed 'not improved at end of course of ECT' 0.79 CI 0.45 to 1.39). One trial showed a significant advantage for 20 treatments over 12 treatments for numbers globally improved at the end of the ECT course (n=43, RR fixed 2.53 CI 1.13 to 5.66).

Authors' conclusions

The evidence in this review suggests that ECT, combined with treatment with antipsychotic drugs, may be considered an option for people with schizophrenia, particularly when rapid global improvement and reduction of symptoms is desired. This is also the case for those with schizophrenia who show limited response to medication alone. Even though this initial beneficial effect may not last beyond the short term, there is no clear evidence to refute its use for people with schizophrenia. The research base for the use of ECT in people with schizophrenia continues to expand, but even after more than five decades of clinical use, there remain many unanswered questions regarding its role in the management of people with schizophrenia.

 

Plain language summary

Electroconvulsive therapy for schizophrenia

The induction of a seizure (fit) for therapeutic purposes by the administration of an electrical stimulus (electroconvulsive therapy or ECT) remains a common treatment option for people with schizophrenia. This review pools data from 26 studies that included over 798 participants in receipt of this treatment. The evidence suggests that courses of ECT can, in the short term, result in an increase in global improvement for some people with schizophrenia.

 

摘要

背景

電氣痙攣療法使用在精神分裂

電氣痙攣療法(ECT)是牽涉藉由給予某頻率電刺激到頭皮上的電極片以引發癲癇達到期治療目的，它使用在精神分裂症的作用是不清楚的

目標

評估電氣痙攣療法在精神分裂症患者就整體、住院狀況、心理狀態改變、及行為跟功能上是否臨床上具有意義的優勢，評估是否電氣痙攣療法實際上使用的變動是否影響結果

搜尋策略

我們電腦搜尋Biological Abstracts (1982 – 1996)、EMBASE(1980 – 1996)、 MEDLINE(1966 – 2004)、PsycLIT(1974 – 1996)、SCISEARCH(1996)及Cochrane Schizophrenia Group's Register (2004年7月)。我們也檢查了所有的確定研究的參考文獻和也跟相關作者聯繫

選擇標準

我們納入所有使用在精神分裂症、情感性精神分裂症或慢性心理疾病，以ECT比較安慰劑、偽ECT、非藥物介入及抗精神病藥臨床及不一樣的療程跟不一樣施予ECT方式的隨機控制試驗

資料收集與分析

分別獨立工作，我們嚴格挑選和評價研究，提取數據，並以意向性治療的基礎分析。在可能和適當下，我們計算相對風險(RR)及其95％可信賴區間(CI)與益一需治數(NNT)。對於連續數據，我們計算加權平均數差異(WMD)。我們只提出已經達到預定品質工具的量表數據。我們還對異質性和發表資料偏差進行了測試

主要結論

這個回顧包括了26個試驗及其50篇報告，當ECT和安慰劑或偽ECT比較時，在真正施行ECT這組，有更多的人改善(n = 392, 10 RCTs, RR 0.76 random CI 0.59 to 0.98, NNT 6 CI 4 to 12)且資料具有異質性(chisquare 17.49 df = 9 P = 0.04)，它的變異性影響的數據是不具有實質性(Isquared 48.5%)。ECT比偽ECT顯示比較少短期再復發(n = 47, 2 RCTs, RR fixed 0.26 CI 0.03 to 2.2)，及比較有可能康復出院(n = 98, 1 RCT, RR fixed 0.59, CI 0.34 to 1.01)。沒有證據顯示這些早期的優勢，會維持治中期至長期。使用ECT治療的患者比偽ECT沒有較早退出治療(n = 495, 14 RCTs, RR fixed 0.71 CI 0.33 to 1.52, Isquared 0%)。非常有限的資料顯示視覺記憶ECT比偽ECT可能衰退(n = 24, 1 RCT, WMD −14.0 CI −23 to −5)，而言語記憶測試的結果則是模?兩可。當ECT直接和藥物比較顯示藥物(total n = 443, 10 RCTs)比較有效(n = 175, 3 RCTs, RR fixed ‘not improved at the end of ECT course’ 2.18 CI 1.31 to 3.63)。有限的證據顯示ECT合併抗精神病藥物相較單以藥物治療在心理狀態有大幅的改善(n = 40, 1 RCT, WMD, Brief Psychiatric Rating Scale −3.9 CI −2.28 to −5.52)。有一個小的研究認為ECT療程合併抗精神病藥物相較單以藥物治療有較多的記憶缺損 (n = 20, MD serial numbers and picture recall −4.90 CI −0.78 to −9.02)，雖然這是短暫的。當連續ECT加上藥物治療優於單獨藥物治療(n = 30, WMD Global Assessment of Functioning 19.06 CI 9.65 to 28.47)，或者優於單獨ECT治療(n = 30, WMD −20.30 CI −11.48 to −29.12)。在整體改善上，單極跟雙側性電及是相當的效果(n = 78, 2 RCTs, RR fixed ‘not improved at end of course of ECT’ 0.79 CI 0.45 to 1.39)。有一個試驗顯示在ECT最後的整體改善上，20個ECT治療個案有明顯的好處相較於12個治療個案(n = 43, RR fixed 2.53 CI 1.13 to 5.66)

作者結論

在這次回顧證明，ECT治療合併抗精神病藥物治療，可被視為在治療精神分裂症患者的一種選擇，特別是想要當迅速全面改善症狀及減少症狀。對於只使用抗精神病藥物治療有限的個案也是如此。雖然這初期的有利影響可能不會持續超過短期，但沒有明確的證據來駁斥其使用在患有精神分裂症的患者身上。此使用ECT在精神分裂症個案的研究基礎不斷擴大，但即使已經過 50多年的臨床使用，但仍然存在許多懸而未決的問題，如其角色作用在處理精神分裂症的人

翻譯人

本摘要由彰化基督教醫院許文郁翻譯

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌

總結

給予一個電流刺激(電氣痙攣療法或ECT)引發發作(小發作)以達到治療目的仍然是人們常用治療精神分裂症的選擇。這回顧統合26個研究包括了798位參與個案接受這種治療。證據顯示在短期ECT療程可以在一些精神分裂症患者中增加期全面性的改善