97. GLOBAL VARIATIONS IN ELECTROCONVULSIVE THERAPY USAGE: A COMPARATIVE CASE SERIES ON SCHIZOPHRENIA IN THE UNITED STATES

Introduction

Electroconvulsive Therapy (ECT) is an established treatment for treatment-resistant depression (TRD), and severe psychiatric conditions, including schizophrenia, schizoaffective disorder, catatonia (Kellner et al., 2012). Globally, ECT application varies significantly, particularly between depression and schizophrenia. In the United States, ECT is used for treating major depressive disorder, whereas treatment for schizophrenia is less common. Conversely, in many Asian countries, including Japan, and regions in the Middle East, ECT is more frequently administered for schizophrenia (Chanpattana et al., 2005; Chapattana et al., 2010; Younis et al., 2022). A survey of 23 Asian countries showed that 41.8% of ECT treatments were for schizophrenia compared to 32.4% for major depression (MDD)(Chanpattana et al., 2005). ECT literature from Japan reports similar trends, while in countries such as Spain and Switzerland ECT are primarily used for depression (up to 80% of treatments in reported literature) (Chanpattana et al., 2005; Vera, et al., 2016; Wilhelmy, et al., 2023). This analysis explores whether differences in ECT usage between depression and schizophrenia stem from treatment efficacy or are shaped by medical cultural differences. Despite the proven effectiveness of ECT treatment for other conditions outside of major depression or treatment-resistant depression, global usage of ECT is inconsistent with published literature as arbitrary restrictions limit access for patients with severe mental illnesses (Tor et al., 2021).

Methods

A case series including three cases of the use of electroconvulsive therapy (ECT) to treat geriatric patients with schizoaffective disorder. Patient symptomatic response and clinical improvement were assessed with the Clinical Global Impression-Improvement (CGI-I) and Clinical Global Impression-Severity (CGI-S). Stabilization of mood was assessed with the Beck Depression Inventory (BDI), Generalized Anxiety Disorder 7-item (GAD-7), and Patient Health Questionnaire-9 (PHQ-9).

Results

Case 1: 30-year-old male with a longstanding diagnosis of obsessive-compulsive disorder, autism spectrum disorder, and schizoaffective disorder, depressive type, who presented with a series of paranoia episodes over the series of a year. ECT was recommended to the patient as he was a prior responder; he received 77 ECT treatments in the clinic. Marked improvement in hallucinations, delusions, and speech latency were observed after five treatments. By ECT #11, the patient showed significant remission of psychotic symptoms and notable mood stabilization with a CGI-I of 1. By ECT #77, CGI-I was 2, CGI-S was 3, BDI was 13, GAD-7 was 4, and PHQ-9 was 6.

Case 2: 48-year-old female with bipolar type schizoaffective disorder who presented with paranoia, delusions, anxiety, depression and mania. The patient previously received 22 ECT treatments the year before for refractory psychosis and depression; she received 54 ECT treatments in the clinic. At ECT initiation, the patient had a CGI of 6, BDI of 34, GAD-7 of 13, and PHQ-9 of 13. Symptomatic relief from paranoia and anxiety was apparent by the ECT #18, with a CGI-I of 3 and CGI-S of 5 along with gradual mood stabilization and reduction in manic episodes. By ECT #54, the patient reported a CGI-I score of 2, CGI-S of 2, BDI of 25, GAD-7 of 14, and PHQ-9 of 5.

Case 3: 48-year-old male with depressive type schizoaffective disorder and fluctuating degrees of paranoia. The patient received 7 ECT treatments. Before treatment, CGI-S was 6, BDI was 39, and PHQ-9 was 22. After ECT #4, minimal improvements in paranoid thoughts and depressive mood were reported with a given CGI-I of 3, CGI-S of 5, BDI-II of 33, and PHQ-9 of 9.

Conclusions

Studies have shown that ECT treatment improves general functioning and reduction in verbal aggression and self-harm even extending towards C/M ECT (Continuation/Maintenance Electroconvulsive Therapy), demonstrating the efficacy and safety of this treatment and its underutilization for schizophrenia (Iacu et al., 2015; Purohit et al., 2022). The wide variation amongst other countries in the use of ECT for the treatment of schizophrenia demonstrates that this is not a medical cultural difference and may be more indicated in patients with psychotic disorders including schizophrenia and schizoaffective disorder (Sanghai et al., 2018). Research have demonstrated positive outcomes of ECT treatment in schizophrenia (and schizoaffective disorder) patients, highlighting the need for a wider approach to its application in countries.