From its beginning in 1938 through to the 1950s, ECT enjoyed considerable popularity for the treatment of schizophrenia. As one of the very few available treatments, it appeared to offer rapid alleviation of psychotic symptoms, particularly in the acutely ill, and was said to be without significant risks. Nevertheless, the availability of antipsychotic drugs from 1953, together with increasing opposition to the use of ECT, led to its gradual decline through the 1960s and 1970s (Fink, 2001). A resurgence of interest in the 1980s in its use to augment the action of drugs in individuals resistant to antipsychotics was eclipsed with the arrival of atypical antipsychotics, particularly clozapine, for the pharmacotherapy of treatment-resistant schizophrenia. The finding that a proportion of patients have symptoms that fail to respond to clozapine has prompted investigation of combining this drug with ECT. In addition, many psychiatrists see ECT as the treatment of choice for catatonic schizophrenia.
It is remarkable that, despite being available for more than 60 years, there are few good-quality controlled trials of ECT for schizophrenia. This has not been rectified since the publication of the previous edition of The ECT Handbook (Scott, 2005), but a number of excellent reviews of the evidence is available (Johns & Thompson, 1995; Krueger & Sackeim, 1995; Fink & Sackeim, 1996; Lehman et al, 1998). These were supplemented by a systematic review as part of the Cochrane Collaboration (Tharyan & Adams, 2005). This chapter has been updated slightly to incorporate additions to the literature since the last edition of the Handbook.
A comparison of real ECT against ‘sham’ ECT is the most rigorous method of establishing efficacy, comparable to a pharmaceutical placebo-controlled trial. In sham ECT, the control group undergoes the full ECT procedure with the exception of the stimulus, controlling for all extraneous influences on outcome. The design was developed in the 1950s, and it often included a group who received a subconvulsive stimulus. These studies are fraught with ethical and methodological difficulties and few have been published since 1965. Moreover, a lack of operationalised diagnostic criteria, compounded by an overinclusive approach to schizophrenia in the USA, often resulted in the misdiagnosis of affective psychoses.