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LETTER TO EDITOR Table of Contents   
Year : 2005  |  Volume : 47  |  Issue : 4  |  Page : 245
Combination of ECT and clozapine in drug-resistant schizophrenia

Department of Psychiatry, Christian Medical College, Vellore, India

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Date of Web Publication19-Sep-2009

How to cite this article:
Kurian S, Tharyan P, Jacob K S. Combination of ECT and clozapine in drug-resistant schizophrenia. Indian J Psychiatry 2005;47:245

How to cite this URL:
Kurian S, Tharyan P, Jacob K S. Combination of ECT and clozapine in drug-resistant schizophrenia. Indian J Psychiatry [serial online] 2005 [cited 2021 Apr 18];47:245. Available from:


We read the article by Kumar et al. [1] with interest. The authors have described the development of delirium in a 56-year-old patient who was treated with a combination of electroconvulsive therapy (ECT) and clozapine, and advised caution in the use of this treatment combination. We discuss this issue based on a review of the literature and our clinical experience.

We used a combination of clozapine and ECT in 3 men (21, 24 and 33 years of age) with schizophrenia resistant to treatment with conventional and atypical antipsychotic medications. They were on 350-450 mg of clozapine per day. They received a course of 8-10 ECTs each. They did not have significant cognitive deficits or delirium and completed their courses of ECT. All the 3 patients showed a 40%-50% reduction in their Brief Psychiatric Rating Scale (BPRS) scores.

The literature also supports the use of a combination of ECT and clozapine in those with drug-resistant schizophrenia. Williams et al. [2] have suggested the use of the term 'neuroleptic­resistant schizophrenia' as a more positive alternative to the term 'treatment-resistant schizophrenia' and have also examined the treatment options for patients resistant to clozapine mono­therapy. Combination with ECT is quoted as a safe and clinically beneficial strategy. Other reports, barring initial concerns about the risk of spontaneous or prolonged seizures with this combination, [3] also describe the combination of ECT and clozapine to be safe and clinically effective. [4],[5],[6],[7],[8] Combining ECT and clozapine has also been advocated for achieving rapid control of disturbed behaviour, when time does not allow for dose titration with clozapine as monotherapy. [9]

Delirium and cognitive deficits during ECT are caused by several factors. In the study by Kumar et al., older age, the number and frequency of ECTs, the type and strength of current used, the position of the electrodes or the concomitant use of medication could have resulted in the delirium. Though current guidelines based on case reports do not proscribe the use of ECT with clozapine, [10] definite guidelines on the safety and efficacy of this combination will have to await the results of the ongoing National Institute of Mental Health (NIMH)­sponsored, multicentre, randomized, open-label efficacy trial comparing ECT augmentation of clozapine versus clozapine monotherapy. [11] While the combination of ECT and clozapine demands caution, this approach should not be denied to patients with clozapine-resistant schizophrenia.

   References Top

1.Kumar S, Goswami U, Behera D, et al. ECT and clozapine combination producing delirium: A case report. Indian J Psychiatry 2003;45:193.  Back to cited text no. 1      
2.Williams L, Newton G, Roberts K, et al. Clozapine-resistant schizophrenia: A positive approach. Br J Psychiatry 2002; 181:184-7.  Back to cited text no. 2      
3.Bloch Y, Pollack M, Mor I. Should the administration of ECT during clozapine therapy be contraindicated? Br J Psychiatry 1996;169:253-4.  Back to cited text no. 3      
4.Benatov R, Sirota P, Megged S. Neuroleptic-resistant schizo­phrenia treated with clozapine and ECT. Convuls Ther 1996; 12:117-21.  Back to cited text no. 4      
5.Bhatia SC, Bhatia SK, Gupta S. Concurrent administration of clozapine and ECT: A successful therapeutic strategy for a patient with treatment-resistant schizophrenia. J ECT 1998; 14:280-3.  Back to cited text no. 5      
6.Cardwell BA, Nakai B. Seizure activity in combined clozapine and ECT: A retrospective view. Convuls Ther 1995;11:110-13.  Back to cited text no. 6      
7.Safferman AZ, Munne R. Combining Clozapine with ECT. Convuls Ther 1992;8:141-3.  Back to cited text no. 7      
8.Sedgwick JV, Lewis IH, Linter SP. Anaesthesia and mental illness. Int J Psychiatry Med 1990;20:209-25.  Back to cited text no. 8      
9.James DV, Gray NS. Elective combined electroconvulsive and clozapine therapy. Int Clin Psychopharmacol 1999;14:69-72.  Back to cited text no. 9      
10.American Psychiatric Association Committee on Electro­convulsive Therapy. The practice of electroconvulsive therapy: Recommendations for treatment, training and privileging. A task force report of the APA. 2nd ed. Washington: APA; 2001.  Back to cited text no. 10      
11.National Institute of Mental Health. Electroconvulsive therapy in clozapine refractory schizophrenia. Available from URL: order=6.  Back to cited text no. 11      

Correspondence Address:
K S Jacob
Department of Psychiatry, Christian Medical College, Vellore
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0019-5545.43067

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