- Email: [email protected]
Electroconvulsive treatment for schizophrenia. A ten-year survey in a university hospital psychiatric department
Comprehensive Psychiatry Official Journal
VOL.
of the American
Psychopathological
Association
JULY/AUGUST
14, NO. 4
1973
Electroconvulsive Treatment for Schizophrenia. A Ten-Year Survey in a University Hospital Psychiatric Department Dorm A. Wells
T
HIS report reviews the use of a first course of electroconvulsive treatment (ECT) for schizophrenia on the inpatient service of a university hospital department of psychiatry during 1960-1969. Convulsive treatment has a long history in psychiatry. The use of chemically induced convulsions for psychosis was reported in medical literature of the 18th and 19th Centuries, but convulsive therapy was not widely investigated until the early 1930’s.’ It was the hypothesis of an antagonism between epilepsy and schizophrenia which provided the rationale for study of the therapeutic efficacy of convulsive treatment. Camphor and other seizure-producing drugs were experimented with through the 1930’s but all of these involved unpleasant side effects or technical difficulties in administration. Shortly after Cerletti and Bini’ introduced the technique of electrically induced convulsions in 1938, reports such as those of Kalinowsky and Worthing-’ describing very good results led to extensive use of ECT for schizophrenia. However, as the years passed and follow up studies could be obtained, it began to appear that improvement of psychotic symptoms following ECT was transitory at best.4 In the 1960’s, Tourney5 and Riddell reviewed the literature and suggested that there is little proof of significant lasting benefit obtained from this type of treatment. The recent investigation of treatment methods for schizophrenia carried out by May’ indicated that ECT is more effective than psychotherapy alone or a milieu approach alone, but also found ECT to be less effective than either the major tranquilizers alone or the drugs with psychotherapy. In the 1969 edition of his book,* and in his chapter in the 1967 Friedman and Kaplan textbook,’ Kalinowsky continues to speak favorably of ECT for schizophrenia. He emphasizes the necessity of long courses of ECT if results are to be expected, and also recommends its early use for acute symptomatology, after a trial of pharmacotherapy. Yet, in 1968, Turnal wrote “there is still no con-
From the University of Rochester School of Medicine and Dentistry. Rochester. N. Y. Donn A. Wells, M.D.: Assistant Professor of Psychiatry. Department of Psychiatr_v. Rochester School of Medicine and Dentistry. Rochester, N. Y. 14642. CCI973 by Grune & Stratron, Inc. Comprehensive Psychiatry. Vol. 14. No. 4 (July/August), 1973
University
o/’
291
292
DONN A. WELLS
elusive evidence regarding indications for ECT in schizophrenia and no theory of its mode of action.” At present, opinions continue to vary concerning this method of treatment. There are hospitals which no longer use ECT, others which may limit its use to treatment of depressive illness, and others yet which still find a place for ECT in the treatment of some patients with schizophrenia. The present review grew from an interest in the manner in which the psychiatric staff of one university hospital has responded to the conflicting suggestions in the literature regarding this treatment modality. METHOD The Department of Psychiatry of the University of Rochester Medical Center operated an 87bed inpatient service prior to 1969, when in midyear an additional 22-bed facility was opened, There are four floors, all well staffed with nurses, assistants, residents. medical students, interns, psychologists, and clinical directors. Patients with a very wide variety of psychiatric disorders are cared for with pharmacotherapy, ECT, individual, group and family psychotherapy and behavior therapies. ECT always requires a physician’s order and the patients’ written consent. All treatments are supervised by both a physician and an anesthesiologist. During the 1960’s. approximately 400 patients admitted to this hospital with schizophrenia were treated with ECT, many of them several times. During this time there were 3790 discharges of patients with a diagnosis of schizophrenia. Only those patients who were being given ECT for the first time were chosen for the present report. An attempt was made to determine some basic characteristics of these schizophrenic patients and the criteria used in their selection for ECT. The short-term outcome of treatment was surveyed, and differences were noted between patients who responded well and those who did not respond. Attention was given to evidence of disagreements over diagnoses and to the data used to diagnose schizophrenia in these patients. The technique, frequency, and duration of treatment was also noted. The decade 1960-1969 was selected as it was a time when ECT was routinely given on all wards. The prevailing attitude of the department staff toward ECT was an accepting one. Throughout this time, the major tranquilizers were well established as a treatment for schizophrenia and were being used regularly. The records of all patients who received a first course of ECT in this period were identified by means of a computer search in the department’s psychiatric case registry.” The entire chart, including admission workup, progress notes, and discharge summary was then used in collecting the data.
RESULTS
Two hundred seventy-six patients were identified. The number given a first course of ECT showed a general trend toward fewer each year through the decade (Fig. 1). The maximum number of patients in one year was 41, and the lowest number was 13. The percentage of the index group in the group of all patients discharged with schizophrenia each year decreased by over half from 1960 to 1969 (from 11% to 4%). There was also some decrease in the total number of patients with schizophrenia hospitalized in the later third of the decade. Women made up 72% of the group, and men, 28%. This is a ratio of almost three women to each man, in contrast to a 2: 1 female/male ratio among the total population of patients discharged from this hospital with schizophrenia. There is a significant difference in rates of ECT between women and men. (8% vs. 6%, X2 = 6.31). The average age was 35, with a spread from 17 to 85
ELECTROCONVULSIVE
293
TREATMENT
TOTAL DEPARTMENT PSYCHIATRICADMISSIONS ALL DIAGNOSES
L DEPARTMENTALTOTALS: 500
TOTAL DISCHARGES WITH DIAGNOSISOF SCHIZOPHRENIA
400
300
I
l
J
1
200
Fig. 1. Departmental statistics on admission for schizophrenia and ECT.
PATIENTS WITH SCHIZOPHRENIASTARTED ON ECT. AND PERCENTOF TOTAL DISCHARGESFOR SCHIZOPHRENIA
100 0I
I
1 I
I
I
1 1
1W ‘61 ‘62 ‘63 ‘64 ‘65 ‘66 ‘67 ‘60 ‘69
years. About half (52%) of these patients were admitted for their first episode of schizophrenia, and the rest had been previously hospitalized from one to five times. The onset of symptoms had occurred within six months of hospital admission for 85% of the group. The average length of hospitalization was 39 days, with a range from several weeks to several months. This is only slightly longer than the average length of stay for all patients on these wards. Patients were in the hospital an average of 14 days before ECT was started, Psychiatric evaluation indicated that moderate to severe depression was a significant problem for 76% of the group. For 54”:, depression was the most prominent difficulty described. Thought disorder alone, without depressive features, was noted for 237;. Four patients were described as hypomanic, and this diagnosis was debated in the records but they were discharged with a diagnosis of schizophrenia. The diagnosis of schizophrenia was questionable as determined by differing clinical impressions or psychological testing results, in a total of 30 cases (1 IS/,). See Table 1 in relation to these data. The relative frequency of the various subtypes of schizophrenia in the group is shown in Table 2. Sixty per cent of these patients were felt to have paranoid or schizoaffective schizophrenia. The “other” category included such diagnostic labels as pseudoneurotic, simple, and hebrephrenic schizophrenia. The decision to give ECT was made after a trial of a phenothiazine drug in every case. Doses used varied according to individual tolerance and rarely exceeded 1000 mg/day. Many patients had received drug treatment on an out patient basis and some were brought to the hospital specifically for electroconvulsive therapy after drugs had failed to bring improvement. Most of these were given a further trial on medication plus the hospital mileau before ECT was started. Lack of improvement with drugs and milieu treatment was the primary reason given in the records for using ECT. The other major factor noted was
294
DONN A. WELLS Table 1. Two Hundred Seventy-six Patients With Schizophrenia Treated With ECT (1960-1969) Most Prominent
Symptom
Thought Thought
Disorder and Women
Average
Sl%ere
Moderate
Disorder
“HYpo-
Dlagnosls
Age
Depression
Depresston
AlO%?
manic”
Uncertain
35
148
Men
200
76 28%
72%
54%
61
63
4
30
22%
23%
1%
11%
Symptom Improvement Average First Episode
144
Average
Days
Days
In Hospital
Average
Acute
In
Before
Number
onset
Hospital
ECT
of ECT
39
14
7
(~6 mo)
Dispcwtion
ECT QOD
268
ModGood
102
crate
106
Home
Home
Mimmal
With
No
LongTerm
or
Med!-
Medl-
Hospital-
N0lle
cation
cation
ization
68
168
85
23
235 52%
(2-22)
85%
97%
37%
38%
25%
61%
31%
8%
the presence and persistence of depressive complaints. Another reason given was the presence of catatonic symptoms, particularly bizarre posturing or uncontrolled excitement. All patients received barbiturate anesthesia and succinyl choline for seizure modification. Three patients were given unilateral treatments, the rest had bilateral electrode placement, usually using 0.4 seconds at 140 volts. Ninety-seven per cent were treated every other day, three times weekly. Only eight patients received daily treatments. The average number of treatments given was seven, (range 2-22). 72”/, (200 patients) of the group received between four to eight treatments. that there Improvement was rated as being “good” if the record indicated was complete remission of clinical signs of thought disorder, clearing of depression, and manifestation of adequate control of behavior. Moderate improvement was ascribed to those who were still evidencing some clinical signs of thought disorder but who were less depressed and/or were in good control of their behavior after treatment. Thirty-seven per cent of the group showed good Table 2. Acute Symptom Improvement by Diagnostic Types (1960-1969) Total Number of Patients
Good
Moderate
Mmtmal-None
Paranoid
(34%)
32 (34%)
34 (37%)
27 (29%)
Schizo-affective schizophrenia
73 (26%)
29 (40%)
33 (45%)
11 (15%)
Undifferentiated schizophrenia
60 (22%)
19 (32%)
22 (37%)
19 (31%)
Catatonic schizophrenia
33 I1 2%)
18 (55%)
9 (27%)
6(18%)
Other schizonhrenia
17(
4 (24%)
8 (47%)
5 (29%)
schizophrenia
93
6%)
ELECTROCONVULSIVE
TREATMENT
295
improved (Table 1). Thus, 759; were improvement, and 383; were moderately felt to have received some benefit from ECT. Among the various subtypes of schizophrenia described, those with catatonic and schizoaffective schizophrenia did best. Eighty-five per cent with schizoaffective schizophrenia showed moderate or good improvement and 82’, with catatonic schizophrenia improved. (Table 2). Of the 200 women in the entire index group, 75q< showed good or moderate improvement with ECT and 76”, of the 76 men showed similar improvement. Thus, there was no difference in improvement on a sexual basis alone. Ninety-two per cent of the patients were discharged to their homes and the rest were transferred to a long-term care institution. 61’; of those who went home were discharged on medication. Follow up data on these patients is still being obtained and was not considered part of this study, but there are 95 patients on whom two years or more of follow up is available. Of these, 44 (469;) had relapses requiring some form of treatment, inpatient or outpatient, within two years. As so many of these patients presented with primarily depressive complaints, (54”,), the clinical features were noted which led to a diagnosis of schizophrenia rather than psychotic depression. In many cases, these patients demonstrated a flattened or dulled affect rather than a profoundly depressive affect, in spite of their prominent complaints of depressive symptoms. A history of a schizoid premorbid life, or of paranoid delusions and hallucinations weighted the diagnosis in favor of schizophrenia. Although some patients might have been described as psychotically depressed, their relatively young age led staff to prefer a diagnosis of schizophrenia. And finally, there were some patients who were considered primarily depressed until a lack of response to ECT led to a suspicion of an underlying schizophrenic problem. The following brief case report illustrates some of these features: A 25yearold, single, white, employed, Catholic woman was admitted with a one month history of obsessive ruminations over fantasies of sexual indiscretion, frequent crying, somatic complaints and a belief that co-workers felt that she was pregnant. She also complained of loss of appetite, constipation, and sleep disturbance. These symptoms developed shortly after her parents moved to another state, uprooting the home she had lived in all her life, and leaving her living alone for the first time. Raised by a passive, irresponsible father and a strong, dominating mother, this woman had always been known as an indecisive, dependent person who was easily guided by her mother’s wishes. Clinical exam in the hospital revealed her to be very anxious with prominent guilt feelings about the most benign behavior. She was depressed and withdrawn. There were no gross signs of dissociation and her sensorium was clear. She was physically well. Formal psychological testing was not done. With a month’s treatment on 600-800 mg chlorpromazine a day, she took much distance from her delusions and appeared much more relaxed. She was discharged on medication. She was followed in the clinic over the next three months, and her symptoms gradually returned, particularly her ruminations over guilt feelings about benign past experiences. She then took an overdose of
296
DONN
Table 3. Comparison:
Good Improvement
or No Improvement
A.
WELLS
Group vs. Minimal
Group Most Promment
Sympton
Thought Disorder Average Group
WClllleIl
MelI
Age
(102)
(74)
(28) 27%
34
Good
73%
Severe
Moderate
Thought
First
Depression
Depression
Disorder
Epkwde
(62) 61%
(16)
(27) 40%
(24) 24%
(55)
(16)
(25)
(21)
23%
37%
31%
15%
54%
Improvement (68)
(51)
(17)
or
75%
25%
Minimal
34
no improvement
Disposition Acute
Average
Days
Average
onset
Days in
Before
Number
Uncertain
Hospital
ECT
ECT
Diagnosis
(<6
mo)
(87) 85%
Hospltal
(17) 38
13.7
5
(55)
81%
Other Home
40
13
7
17%
100%
(5)
(45)
7%
66%
(23)
34%
sedatives, was readmitted to the hospital, and was given 9 ECT while being continued on 300 mg of phenothiazine daily. Her mood improved rapidly, her anxiety was greatly relieved, she became more confident and appropriate in social interactions, and she was discharged as greatly improved. The diagnoses discussed were acute undifferentiated schizophrenia vs. manic-depressive psychosis, and the discharge diagnosis was schizophrenia. In order to investigate further the possibility of certain features which correlated with good improvement, the data obtained from the 102 patients who did best was compared with that from the 68 patients who did not improve or improved only minimally (Table 3). The sex ratio is the subgroups was the same as in the entire index group, with three times as many women as men. There was no significant difference between the two groups in terms of age, time of onset of symptoms, length of hospitalization, or number of treatments given. (Although those who did not improve received a slightly greater average number of treatments.) There was significantly better improvement for those with severe depressive symptoms than there was for those with thought disorders alone or thought disorders and moderate depression (X2 = 7.27, 2 df, p = .025). A significantly greater number of patients were having a first episode of symptoms among the group which improved most (54% vs. 31x, X2 = 7.85, p = .005). There was a larger number with uncertain diagnoses among the group which did best, but the difference was not significant (X2 = 2.36). DISCUSSION
Although this review indicates a trend toward starting fewer schizophrenic patients on ECT in this hospital, it also shows that this treatment continues to be given to certain patients with good short-term results. The fact that few
ELECTROCONVUCSIVE
297
TREATMENT
patients receive an extended course of treatment suggests that ECT is no longer viewed here as a curative approach, but rather as a means of bringing about more rapid symptom relief, after drugs have been tried, allowing other therapies to then work more effectively. The data indicates too, that ECT has not been considered by the staff to be “only a last resort” treatment. It has been accepted as particularly useful for some patients quite early in their illness. The schizophrenic patient most likely to be selected for ECT at this facility might be characterized as a woman in her 30’s with an acute onset of symptoms suggesting paranoid or schizoaffective schizophrenia, with prominent depressive complaints. She will have received a trial of at least several weeks on phenothiazines. Those who do best seem to be the patients who are experiencing their first episode of psychosis and whose main symptoms are depressive or catatonic. For some, the depressive component is prominent enough to raise questions of the possibility of psychotic depression. The fact that ECT has been given to a somewhat older population might have to do with a tendency of staff to view younger patients as more amenable to an interpersonal, psychotherapeutic approach. It is more difficult to propose explanations for the choice of so many more women than men to receive ECT, but it is noteworthy in light of May’s7 finding that ECT was less effective for women than for men. In this group, the women did as well as the men. SUMMARY
The use of ECT for schizophrenia has been declining in the University Hospital studied. During the 1960’s it was given for the first time to selected patients with all forms of schizophrenia, especially those in their 30’s with less than six months of symptoms including a prominent affective component, and who had an unsuccessful trial on phenothiazines. The standard technique has been to give modified seizures every other day using bilateral electrode placement. Most patients received from four to eight treatments. Moderate to good immediate clinical improvement was obtained for threefourths of the index group. Those with schizoaffective or catatonic schizophrenia, and those treated during a first episode of symptoms which included prominent depression tended to do best. ACKNOWLEDGMENTS I wtsh to thank Ms. June Heriot,
Dr. Charles OdorotT, University of Rochester, Division Division of Preventive Psychiatry for their assistance.
of Bio Statistics.
and
REFERENCES I. Kennedy A: The treatment of mental disorders by induced convulsions. J Neural Psychiatry 3:49-82, 1940 2. Cerletti U. Bini L: L’elettroshock. Arch Gen Neurol Psichiat Psichoanaly 19:266-268, 1938 3. Kalinowsky LB, Worthing HJ: Results with electric convulsive treatment in 200 cases of schizophrenia. Psychiat Q 17: 144-l 53, 1943
4. Hoch PH: Progress in psychiatric therapies. Am J Psychiatry 112:241-247. 1955 5. Tourney G: A history of therapeutic fashions in psychiatry, 1800-1966. Am J Psychiat 124:784-796, 1967 6. Riddell SA: The therapeutic efficacy of ECT. Arch Gen Psychiatry 8:546-556, 1963 7. May PR: Treatment of Schizophrenia: A Comparative Study of Five Treatment
298
Methods. New York, Science House, 1968, p 231-232 8. Kalinowsky LB, Hippins H: Pharmacological, Convulsive and Other Somatic Treatments in Psychiatry. New York, Grune & Stratton, 1969, p 242 9. Freedman AM, Kaplan HI: Comprehensive Textbook of Psychiatry. Baltimore,
DONN A. WELLS
Williams & Wilkins, 1967, p 1279 IO. Tuma AH: Treatment of schizophreniaAn historical perspective, in May PR (ed): Treatment of Schizophrenia-A Comparative Study of Five Treatment Methods. New York, Science House, 1968, p 43 I I. Miles H, Gardner E: A psychiatric case register. Arch Gen Psychiat 14:571~580, 1966
VOL.
of the American
Psychopathological
Association
JULY/AUGUST
14, NO. 4
1973
Electroconvulsive Treatment for Schizophrenia. A Ten-Year Survey in a University Hospital Psychiatric Department Dorm A. Wells
T
HIS report reviews the use of a first course of electroconvulsive treatment (ECT) for schizophrenia on the inpatient service of a university hospital department of psychiatry during 1960-1969. Convulsive treatment has a long history in psychiatry. The use of chemically induced convulsions for psychosis was reported in medical literature of the 18th and 19th Centuries, but convulsive therapy was not widely investigated until the early 1930’s.’ It was the hypothesis of an antagonism between epilepsy and schizophrenia which provided the rationale for study of the therapeutic efficacy of convulsive treatment. Camphor and other seizure-producing drugs were experimented with through the 1930’s but all of these involved unpleasant side effects or technical difficulties in administration. Shortly after Cerletti and Bini’ introduced the technique of electrically induced convulsions in 1938, reports such as those of Kalinowsky and Worthing-’ describing very good results led to extensive use of ECT for schizophrenia. However, as the years passed and follow up studies could be obtained, it began to appear that improvement of psychotic symptoms following ECT was transitory at best.4 In the 1960’s, Tourney5 and Riddell reviewed the literature and suggested that there is little proof of significant lasting benefit obtained from this type of treatment. The recent investigation of treatment methods for schizophrenia carried out by May’ indicated that ECT is more effective than psychotherapy alone or a milieu approach alone, but also found ECT to be less effective than either the major tranquilizers alone or the drugs with psychotherapy. In the 1969 edition of his book,* and in his chapter in the 1967 Friedman and Kaplan textbook,’ Kalinowsky continues to speak favorably of ECT for schizophrenia. He emphasizes the necessity of long courses of ECT if results are to be expected, and also recommends its early use for acute symptomatology, after a trial of pharmacotherapy. Yet, in 1968, Turnal wrote “there is still no con-
From the University of Rochester School of Medicine and Dentistry. Rochester. N. Y. Donn A. Wells, M.D.: Assistant Professor of Psychiatry. Department of Psychiatr_v. Rochester School of Medicine and Dentistry. Rochester, N. Y. 14642. CCI973 by Grune & Stratron, Inc. Comprehensive Psychiatry. Vol. 14. No. 4 (July/August), 1973
University
o/’
291
292
DONN A. WELLS
elusive evidence regarding indications for ECT in schizophrenia and no theory of its mode of action.” At present, opinions continue to vary concerning this method of treatment. There are hospitals which no longer use ECT, others which may limit its use to treatment of depressive illness, and others yet which still find a place for ECT in the treatment of some patients with schizophrenia. The present review grew from an interest in the manner in which the psychiatric staff of one university hospital has responded to the conflicting suggestions in the literature regarding this treatment modality. METHOD The Department of Psychiatry of the University of Rochester Medical Center operated an 87bed inpatient service prior to 1969, when in midyear an additional 22-bed facility was opened, There are four floors, all well staffed with nurses, assistants, residents. medical students, interns, psychologists, and clinical directors. Patients with a very wide variety of psychiatric disorders are cared for with pharmacotherapy, ECT, individual, group and family psychotherapy and behavior therapies. ECT always requires a physician’s order and the patients’ written consent. All treatments are supervised by both a physician and an anesthesiologist. During the 1960’s. approximately 400 patients admitted to this hospital with schizophrenia were treated with ECT, many of them several times. During this time there were 3790 discharges of patients with a diagnosis of schizophrenia. Only those patients who were being given ECT for the first time were chosen for the present report. An attempt was made to determine some basic characteristics of these schizophrenic patients and the criteria used in their selection for ECT. The short-term outcome of treatment was surveyed, and differences were noted between patients who responded well and those who did not respond. Attention was given to evidence of disagreements over diagnoses and to the data used to diagnose schizophrenia in these patients. The technique, frequency, and duration of treatment was also noted. The decade 1960-1969 was selected as it was a time when ECT was routinely given on all wards. The prevailing attitude of the department staff toward ECT was an accepting one. Throughout this time, the major tranquilizers were well established as a treatment for schizophrenia and were being used regularly. The records of all patients who received a first course of ECT in this period were identified by means of a computer search in the department’s psychiatric case registry.” The entire chart, including admission workup, progress notes, and discharge summary was then used in collecting the data.
RESULTS
Two hundred seventy-six patients were identified. The number given a first course of ECT showed a general trend toward fewer each year through the decade (Fig. 1). The maximum number of patients in one year was 41, and the lowest number was 13. The percentage of the index group in the group of all patients discharged with schizophrenia each year decreased by over half from 1960 to 1969 (from 11% to 4%). There was also some decrease in the total number of patients with schizophrenia hospitalized in the later third of the decade. Women made up 72% of the group, and men, 28%. This is a ratio of almost three women to each man, in contrast to a 2: 1 female/male ratio among the total population of patients discharged from this hospital with schizophrenia. There is a significant difference in rates of ECT between women and men. (8% vs. 6%, X2 = 6.31). The average age was 35, with a spread from 17 to 85
ELECTROCONVULSIVE
293
TREATMENT
TOTAL DEPARTMENT PSYCHIATRICADMISSIONS ALL DIAGNOSES
L DEPARTMENTALTOTALS: 500
TOTAL DISCHARGES WITH DIAGNOSISOF SCHIZOPHRENIA
400
300
I
l
J
1
200
Fig. 1. Departmental statistics on admission for schizophrenia and ECT.
PATIENTS WITH SCHIZOPHRENIASTARTED ON ECT. AND PERCENTOF TOTAL DISCHARGESFOR SCHIZOPHRENIA
100 0I
I
1 I
I
I
1 1
1W ‘61 ‘62 ‘63 ‘64 ‘65 ‘66 ‘67 ‘60 ‘69
years. About half (52%) of these patients were admitted for their first episode of schizophrenia, and the rest had been previously hospitalized from one to five times. The onset of symptoms had occurred within six months of hospital admission for 85% of the group. The average length of hospitalization was 39 days, with a range from several weeks to several months. This is only slightly longer than the average length of stay for all patients on these wards. Patients were in the hospital an average of 14 days before ECT was started, Psychiatric evaluation indicated that moderate to severe depression was a significant problem for 76% of the group. For 54”:, depression was the most prominent difficulty described. Thought disorder alone, without depressive features, was noted for 237;. Four patients were described as hypomanic, and this diagnosis was debated in the records but they were discharged with a diagnosis of schizophrenia. The diagnosis of schizophrenia was questionable as determined by differing clinical impressions or psychological testing results, in a total of 30 cases (1 IS/,). See Table 1 in relation to these data. The relative frequency of the various subtypes of schizophrenia in the group is shown in Table 2. Sixty per cent of these patients were felt to have paranoid or schizoaffective schizophrenia. The “other” category included such diagnostic labels as pseudoneurotic, simple, and hebrephrenic schizophrenia. The decision to give ECT was made after a trial of a phenothiazine drug in every case. Doses used varied according to individual tolerance and rarely exceeded 1000 mg/day. Many patients had received drug treatment on an out patient basis and some were brought to the hospital specifically for electroconvulsive therapy after drugs had failed to bring improvement. Most of these were given a further trial on medication plus the hospital mileau before ECT was started. Lack of improvement with drugs and milieu treatment was the primary reason given in the records for using ECT. The other major factor noted was
294
DONN A. WELLS Table 1. Two Hundred Seventy-six Patients With Schizophrenia Treated With ECT (1960-1969) Most Prominent
Symptom
Thought Thought
Disorder and Women
Average
Sl%ere
Moderate
Disorder
“HYpo-
Dlagnosls
Age
Depression
Depresston
AlO%?
manic”
Uncertain
35
148
Men
200
76 28%
72%
54%
61
63
4
30
22%
23%
1%
11%
Symptom Improvement Average First Episode
144
Average
Days
Days
In Hospital
Average
Acute
In
Before
Number
onset
Hospital
ECT
of ECT
39
14
7
(~6 mo)
Dispcwtion
ECT QOD
268
ModGood
102
crate
106
Home
Home
Mimmal
With
No
LongTerm
or
Med!-
Medl-
Hospital-
N0lle
cation
cation
ization
68
168
85
23
235 52%
(2-22)
85%
97%
37%
38%
25%
61%
31%
8%
the presence and persistence of depressive complaints. Another reason given was the presence of catatonic symptoms, particularly bizarre posturing or uncontrolled excitement. All patients received barbiturate anesthesia and succinyl choline for seizure modification. Three patients were given unilateral treatments, the rest had bilateral electrode placement, usually using 0.4 seconds at 140 volts. Ninety-seven per cent were treated every other day, three times weekly. Only eight patients received daily treatments. The average number of treatments given was seven, (range 2-22). 72”/, (200 patients) of the group received between four to eight treatments. that there Improvement was rated as being “good” if the record indicated was complete remission of clinical signs of thought disorder, clearing of depression, and manifestation of adequate control of behavior. Moderate improvement was ascribed to those who were still evidencing some clinical signs of thought disorder but who were less depressed and/or were in good control of their behavior after treatment. Thirty-seven per cent of the group showed good Table 2. Acute Symptom Improvement by Diagnostic Types (1960-1969) Total Number of Patients
Good
Moderate
Mmtmal-None
Paranoid
(34%)
32 (34%)
34 (37%)
27 (29%)
Schizo-affective schizophrenia
73 (26%)
29 (40%)
33 (45%)
11 (15%)
Undifferentiated schizophrenia
60 (22%)
19 (32%)
22 (37%)
19 (31%)
Catatonic schizophrenia
33 I1 2%)
18 (55%)
9 (27%)
6(18%)
Other schizonhrenia
17(
4 (24%)
8 (47%)
5 (29%)
schizophrenia
93
6%)
ELECTROCONVULSIVE
TREATMENT
295
improved (Table 1). Thus, 759; were improvement, and 383; were moderately felt to have received some benefit from ECT. Among the various subtypes of schizophrenia described, those with catatonic and schizoaffective schizophrenia did best. Eighty-five per cent with schizoaffective schizophrenia showed moderate or good improvement and 82’, with catatonic schizophrenia improved. (Table 2). Of the 200 women in the entire index group, 75q< showed good or moderate improvement with ECT and 76”, of the 76 men showed similar improvement. Thus, there was no difference in improvement on a sexual basis alone. Ninety-two per cent of the patients were discharged to their homes and the rest were transferred to a long-term care institution. 61’; of those who went home were discharged on medication. Follow up data on these patients is still being obtained and was not considered part of this study, but there are 95 patients on whom two years or more of follow up is available. Of these, 44 (469;) had relapses requiring some form of treatment, inpatient or outpatient, within two years. As so many of these patients presented with primarily depressive complaints, (54”,), the clinical features were noted which led to a diagnosis of schizophrenia rather than psychotic depression. In many cases, these patients demonstrated a flattened or dulled affect rather than a profoundly depressive affect, in spite of their prominent complaints of depressive symptoms. A history of a schizoid premorbid life, or of paranoid delusions and hallucinations weighted the diagnosis in favor of schizophrenia. Although some patients might have been described as psychotically depressed, their relatively young age led staff to prefer a diagnosis of schizophrenia. And finally, there were some patients who were considered primarily depressed until a lack of response to ECT led to a suspicion of an underlying schizophrenic problem. The following brief case report illustrates some of these features: A 25yearold, single, white, employed, Catholic woman was admitted with a one month history of obsessive ruminations over fantasies of sexual indiscretion, frequent crying, somatic complaints and a belief that co-workers felt that she was pregnant. She also complained of loss of appetite, constipation, and sleep disturbance. These symptoms developed shortly after her parents moved to another state, uprooting the home she had lived in all her life, and leaving her living alone for the first time. Raised by a passive, irresponsible father and a strong, dominating mother, this woman had always been known as an indecisive, dependent person who was easily guided by her mother’s wishes. Clinical exam in the hospital revealed her to be very anxious with prominent guilt feelings about the most benign behavior. She was depressed and withdrawn. There were no gross signs of dissociation and her sensorium was clear. She was physically well. Formal psychological testing was not done. With a month’s treatment on 600-800 mg chlorpromazine a day, she took much distance from her delusions and appeared much more relaxed. She was discharged on medication. She was followed in the clinic over the next three months, and her symptoms gradually returned, particularly her ruminations over guilt feelings about benign past experiences. She then took an overdose of
296
DONN
Table 3. Comparison:
Good Improvement
or No Improvement
A.
WELLS
Group vs. Minimal
Group Most Promment
Sympton
Thought Disorder Average Group
WClllleIl
MelI
Age
(102)
(74)
(28) 27%
34
Good
73%
Severe
Moderate
Thought
First
Depression
Depression
Disorder
Epkwde
(62) 61%
(16)
(27) 40%
(24) 24%
(55)
(16)
(25)
(21)
23%
37%
31%
15%
54%
Improvement (68)
(51)
(17)
or
75%
25%
Minimal
34
no improvement
Disposition Acute
Average
Days
Average
onset
Days in
Before
Number
Uncertain
Hospital
ECT
ECT
Diagnosis
(<6
mo)
(87) 85%
Hospltal
(17) 38
13.7
5
(55)
81%
Other Home
40
13
7
17%
100%
(5)
(45)
7%
66%
(23)
34%
sedatives, was readmitted to the hospital, and was given 9 ECT while being continued on 300 mg of phenothiazine daily. Her mood improved rapidly, her anxiety was greatly relieved, she became more confident and appropriate in social interactions, and she was discharged as greatly improved. The diagnoses discussed were acute undifferentiated schizophrenia vs. manic-depressive psychosis, and the discharge diagnosis was schizophrenia. In order to investigate further the possibility of certain features which correlated with good improvement, the data obtained from the 102 patients who did best was compared with that from the 68 patients who did not improve or improved only minimally (Table 3). The sex ratio is the subgroups was the same as in the entire index group, with three times as many women as men. There was no significant difference between the two groups in terms of age, time of onset of symptoms, length of hospitalization, or number of treatments given. (Although those who did not improve received a slightly greater average number of treatments.) There was significantly better improvement for those with severe depressive symptoms than there was for those with thought disorders alone or thought disorders and moderate depression (X2 = 7.27, 2 df, p = .025). A significantly greater number of patients were having a first episode of symptoms among the group which improved most (54% vs. 31x, X2 = 7.85, p = .005). There was a larger number with uncertain diagnoses among the group which did best, but the difference was not significant (X2 = 2.36). DISCUSSION
Although this review indicates a trend toward starting fewer schizophrenic patients on ECT in this hospital, it also shows that this treatment continues to be given to certain patients with good short-term results. The fact that few
ELECTROCONVUCSIVE
297
TREATMENT
patients receive an extended course of treatment suggests that ECT is no longer viewed here as a curative approach, but rather as a means of bringing about more rapid symptom relief, after drugs have been tried, allowing other therapies to then work more effectively. The data indicates too, that ECT has not been considered by the staff to be “only a last resort” treatment. It has been accepted as particularly useful for some patients quite early in their illness. The schizophrenic patient most likely to be selected for ECT at this facility might be characterized as a woman in her 30’s with an acute onset of symptoms suggesting paranoid or schizoaffective schizophrenia, with prominent depressive complaints. She will have received a trial of at least several weeks on phenothiazines. Those who do best seem to be the patients who are experiencing their first episode of psychosis and whose main symptoms are depressive or catatonic. For some, the depressive component is prominent enough to raise questions of the possibility of psychotic depression. The fact that ECT has been given to a somewhat older population might have to do with a tendency of staff to view younger patients as more amenable to an interpersonal, psychotherapeutic approach. It is more difficult to propose explanations for the choice of so many more women than men to receive ECT, but it is noteworthy in light of May’s7 finding that ECT was less effective for women than for men. In this group, the women did as well as the men. SUMMARY
The use of ECT for schizophrenia has been declining in the University Hospital studied. During the 1960’s it was given for the first time to selected patients with all forms of schizophrenia, especially those in their 30’s with less than six months of symptoms including a prominent affective component, and who had an unsuccessful trial on phenothiazines. The standard technique has been to give modified seizures every other day using bilateral electrode placement. Most patients received from four to eight treatments. Moderate to good immediate clinical improvement was obtained for threefourths of the index group. Those with schizoaffective or catatonic schizophrenia, and those treated during a first episode of symptoms which included prominent depression tended to do best. ACKNOWLEDGMENTS I wtsh to thank Ms. June Heriot,
Dr. Charles OdorotT, University of Rochester, Division Division of Preventive Psychiatry for their assistance.
of Bio Statistics.
and
REFERENCES I. Kennedy A: The treatment of mental disorders by induced convulsions. J Neural Psychiatry 3:49-82, 1940 2. Cerletti U. Bini L: L’elettroshock. Arch Gen Neurol Psichiat Psichoanaly 19:266-268, 1938 3. Kalinowsky LB, Worthing HJ: Results with electric convulsive treatment in 200 cases of schizophrenia. Psychiat Q 17: 144-l 53, 1943
4. Hoch PH: Progress in psychiatric therapies. Am J Psychiatry 112:241-247. 1955 5. Tourney G: A history of therapeutic fashions in psychiatry, 1800-1966. Am J Psychiat 124:784-796, 1967 6. Riddell SA: The therapeutic efficacy of ECT. Arch Gen Psychiatry 8:546-556, 1963 7. May PR: Treatment of Schizophrenia: A Comparative Study of Five Treatment
298
Methods. New York, Science House, 1968, p 231-232 8. Kalinowsky LB, Hippins H: Pharmacological, Convulsive and Other Somatic Treatments in Psychiatry. New York, Grune & Stratton, 1969, p 242 9. Freedman AM, Kaplan HI: Comprehensive Textbook of Psychiatry. Baltimore,
DONN A. WELLS
Williams & Wilkins, 1967, p 1279 IO. Tuma AH: Treatment of schizophreniaAn historical perspective, in May PR (ed): Treatment of Schizophrenia-A Comparative Study of Five Treatment Methods. New York, Science House, 1968, p 43 I I. Miles H, Gardner E: A psychiatric case register. Arch Gen Psychiat 14:571~580, 1966