Korean Medication Algorithm for Schizophrenia-ECT is There


Out on PubMed recently is this expert consensus algorithm:Korean Medication Algorithm for Schizophrenia 2019, Second Revision: Treatment of Psychotic Symptoms.
Lee JS, Yun JY, Kang SH, Lee SJ, Choi JH, Nam B, Lee SH, Chung YC, Kim CH.Clin Psychopharmacol Neurosci. 2020 Aug 31;18(3):386-394. doi: 10.9758/cpn.2020.18.3.386.PMID: 32702217
The abstract is copied below:
Objective: In 2001, the Korean College of Neuropsychopharmacology and the Korean Society for Schizophrenia Research developed the Korean Medication Algorithm Project for Schizophrenia (KMAP-SPR 2001, revised 2006) through a consensus of expert opinion. The present study was carried out to support the second revision of the KMAP-SPR.

Methods: Based on clinical guidelines and studies on the treatment of psychotic symptoms in schizophrenia, the Executive committee completed a draft of KMAP-SPR 2019. To obtain an expert consensus, a Review committee of 100 Korean psychiatrists was formed and 69 responded to a 30-item questionnaire. Based on their responses, the KMAP-SPR 2019 was finalized.

Results: The revised schizophrenia algorithm now consists of 5 stages. At Stage 1, monotherapy with atypical antipsychotics was recommended by expert reviewers as the first-line strategy. At Stage 2, most reviewers recommended the use of typical or atypical antipsychotic drugs not used at Stage 1. At Stage 3, many reviewers agreed with the administration of clozapine. At Stage 4, a combination of clozapine and other agents such as antipsychotics, mood stabilizers, antidepressants, or electroconvulsive therapy was recommended. At Stage 5, most reviewers recommended combined treatment with an antipsychotic other than clozapine; and a mood stabilizer, antidepressant, or electroconvulsive therapy. At any stage, prescribing long-acting injectable antipsychotics at the discretion of the clinician was recommended.

Conclusion: Compared with previous versions, the KMAP-SPR 2019 now recommends using clozapine earlier in treatment- refractory schizophrenia. In addition, the use of long-acting injectable antipsychotics is now considered to be available at any stage.

The pdf is here.

My point in posting this citation is to bring attention to another guideline that at least acknowledges the benefit of ECT in schizophrenia.  Schizophrenia remains the number one indication for ECT worldwide, with a substantial clinical literature to support this use. Despite that, you will recall that FDA could not manage to reach a conclusion that schizophrenia should be among the diagnoses for which ECT was changed to Class II in 2018. 
It is fortunate that ECT made it into the abstract (see highlight, above) of these Korean guidelines; a careful look at table 3 ("Preference of combination strategies for Stage 4") reveals a "preference rate" among the experts of only 1.5% for clozapine plus ECT.
So, at least a consideration of ECT, but certainly no strong endorsement and no consideration of its use in specific situations early in the course of the illness.

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