Treatment Capacity/Clinical Outcomes with ECT in Patients with Schizophrenia/Schizoaffective Disorder in Canada

Out on PubMed, from researchers in Toronto, Canada, is this study:

Treatment Capacity and Clinical Outcomes for Patients With Schizophrenia Who Were Treated With Electroconvulsive Therapy: A Retrospective Cohort Study.

Plahouras JE, Konstantinou G, Kaster TS, Buchman DZ, Foussias G, Daskalakis ZJ, Blumberger DM.Schizophr Bull. 2020 Nov 4:sbaa144. doi: 10.1093/schbul/sbaa144. Online ahead of print.PMID: 33145601

The abstract is copied below:

Background: Patients with schizophrenia are often found incapable to consent to psychiatric treatment. We evaluated clinical outcomes for incapable and capable patients with schizophrenia treated with electroconvulsive therapy (ECT).

Methods: We conducted a chart review of all inpatients treated with an acute course of ECT between 2010 and 2018 at the Centre for Addiction and Mental Health, Toronto, Canada. Short-term outcomes included treatment response and cognitive impairment. We assessed whether incapable patients regained the capacity to consent to treatment. Long-term outcomes included readmissions and subsequent courses of acute or maintenance ECT.

Results: A total of 159 (67%) incapable and 79 (33%) capable patients were included. Patients experienced treatment response (incapable, n = 108, 67.9%; capable, n = 52, 65.8%; P = .771) and few experienced cognitive impairment (incapable, n = 21, 13.2%; capable, n = 19, 24.1%; P = .043). A minority of patients were treated with a subsequent course of acute ECT (incapable, n = 46, 28.9%; capable, n = 16, 20.3%; P = .162). Incapable patients were more likely to be treated with maintenance ECT for at least 6 months (incapable, n = 46, 28.9%; capable, n = 13, 16.5%; P = .039). Both groups had similar readmission rates (incapable, n = 70, 44.0%; capable, n = 35, 44.3%; P = 1.000). Eight (5.0%) incapable patients regained capacity and 7 consented to further treatment.

Conclusions: Irrespective of treatment capacity, the majority of patients demonstrated clinical improvement. Incapable patients experienced less cognitive side effects when compared with capable patients, though they had fewer treatments overall. This study informs clinicians, patients, and substitute decision-makers about the outcomes and challenges of ECT in patients with schizophrenia.

Keywords: capable; incapable; psychiatric illness.

And from the text:

At the end of the acute course of treatment, 8/159 (5.0%) incapable patients regained capacity. At our institution, a new consent is required when patients go on to receive maintenance ECT. Of the patients who developed the capacity to consent to ECT at the end of the acute course, 7/8 (87.5%) chose to continue with maintenance ECT and gave informed consent. In total, 7/91 (7.7%) who were incapable at the start of acute ECT were capable to consent to a maintenance course of treatment. Furthermore, on review of charts, an additional 6/91 (6.6%) of these patients eventually became capable to consent after long-term treatment with maintenance ECT (>6 months of treatment).

...Through this retrospective study, we described the clinical outcomes for capable and incapable patients with schizophrenia and schizoaffective disorder who were treated with ECT. ECT has demonstrated marked effectiveness with rapid symptom amelioration in patients with severe psychosis and catatonia.11,56,57 As such, ECT may be seen as a lifesaving intervention for some patients as the consequences of catatonia can include dehydration, deep vein thromboses, and potentially death related to pulmonary emboli.58 Furthermore, for those patients with severe psychosis and aggression, not pursuing treatment with ECT risks repeated injectable antipsychotics and repeated seclusion room use.59,60 However, ECT is different than other surgical or medical procedures used in patients who cannot consent treatment as it requires repeated administration and works over a period of weeks.

Our study demonstrated that ECT is a clinically effective and safe treatment for incapable and capable patients with schizophrenia and schizoaffective disorder. Although incapable patients were more likely to be treated with a subsequent course of maintenance ECT, a minority of both incapable and capable patients received a subsequent course of acute ECT or experienced readmissions within 6 months of discharge from hospital. Future studies may consider an epidemiological approach and propensity score matching using administrative health system data to evaluate the broader effects of ECT on health service utilization, as well as comparing outcomes in incapable and capable patients in other disorders. Particularly from the ethical perspective of justice, where everyone should be able to participate in research studies, prospective studies in this ill and incapable to consent population should be conducted. The benefits demonstrated in this study and the serious burden of illness in the most severely ill patients with psychosis warrant consideration of strategies on how to conduct prospective research in this population. Further investigations of the potential benefit of ECT for patients with schizophrenia regardless of treatment capacity are warranted.

Despite the retrospective nature of this study and some methodological shortcomings (use of the CGI, idiosyncrasies specific to the legal system in Canada), the data are useful, indeed, compelling. The overriding result is the demonstration of the long-term utility/tolerability of ECT in patients with schizophrenia or schizoaffective disorder. The forensic and ethical issues, very well discussed in the article, are interesting, but really secondary to the clinical results.

The reluctance in the United States to recognize schizophrenia as a major indication for ECT remains puzzling and problematic.