Academic journal article General Psychiatry

Efficacy and Safety of Treating Patients with Refractory Schizophrenia with Antipsychotic Medication and Adjunctive Electroconvulsive Therapy: A Systematic Review and Meta-Analysis

Academic journal article General Psychiatry

Efficacy and Safety of Treating Patients with Refractory Schizophrenia with Antipsychotic Medication and Adjunctive Electroconvulsive Therapy: A Systematic Review and Meta-Analysis

Article excerpt

1. Introduction

About 20-30% of patients with schizophrenia are classified as 'refractory schizophrenia'. [1] The original diagnostic criteria for refractory schizophrenia proposed by Kane in 1995 [2,3] were as follows: 1) partially nonresponsive over the past 5 years when treated with three kinds of antipsychotic medications (at least two of which were of different chemical structures) which were administered at appropriate dosages for a sufficient duration; 2) intolerance of side effects of the antipsychotic medications; and 3) relapse or symptomatic deterioration even when taking sufficient doses of appropriate medication. Other widely accepted criteria of refractory schizophrenia include a duration of illness of more than five years; psychiatric symptoms that show no improvement after two-years of regular, full dose and full course treatment with two kinds of antipsychotics; and no response to clozapine. [2]

The difficulty of treating patients with refractory schizophrenia can lead to a poor quality of life for affected individuals. [3] Clozapine is considered an effective medicine for most patients with refractory schizophrenia, but another therapeutic option considered in several studies is the combined use of antipsychotic medication and electroconvulsive therapy (ECT). [1] However, the findings from these studies have been inconsistent: compared to continued use of standard antipsychotic medications, some studies find the combined use of antipsychotic medication and ECT beneficial, some find it no different, and some find it inferior due to the increased occurrence of memory loss and headache. [4] This paper reports on the first known systematic review and meta-analysis on this topic, combining studies reported both in English and in Chinese.

2. Methods

2.1 Search strategy

We searched the following databases for studies published before May 1, 2015: Pubmed, Excerpta Medica dataBASE (EMBASE), The Cochrane Library, EBSCO, Chinese National Knowledge Infrastructure (CNKI), Chongqing VIP database for Chinese Technical Periodicals, WANFANG DATA, Chinese Biological Medical Literature Database, Taiwan Electronic Periodical Services, and We used the keywords 'refractory,' 'schizophrenia,' 'psychosis,' 'electric shock,' 'electroconvulsive,' 'clinical control study,' 'randomly, placebo', and 'randomly, trial' (and the Chinese equivalents) in the searches. Various combinations of these keywords were used to search for articles, reference lists of included articles were hand-checked for further relevant studies, and experts in the field were asked about ongoing studies.

2.2 Inclusion and exclusion criteria

All reports of randomized controlled trails (RCTs) about the combined treatment of refractory schizophrenia with antipsychotic medications and ECT were screened using the following inclusion criteria: a) a diagnosis of refractory (or 'treatment-resistant') schizophrenia made by psychiatrists; b) the control group was treated with antipsychotic medications; and c) the intervention group was treated with antipsychotic medication and ECT. Studies published in either English or Chinese were considered. Observational studies, anthropologic studies, review articles, research protocols, case reports, and duplicated reports were excluded.

2.3 Screening of articles

All search results were imported into Endnote X5 software. Two authors (WWZ and PCC) independently screened titles and abstracts after eliminating duplicates. The full texts of the remaining articles were screened according to the above inclusion and exclusion criteria. When the two authors disagreed about the inclusion of an article and were unable to agree after discussing the article, a third author (LCB) made the final determination. As shown in Figure 1, 22 studies were included in the final analysis.

2.4 Evaluation of risk of bias

Two authors (WWZ and PCC) assessed the risk of bias independently for all included articles using the Cochrane Risk of Bias (RoB) [5] tool which considers seven specific items: random sequence generation; allocation concealment; blinding of participants and treating clinicians about group assignment; blinding of evaluators of outcomes about group assignment; incomplete data (attrition and exclusions); selective outcome reporting; and other biases (including study-specific biases or concerns about fraudulent results). …

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