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ECT Augmentation of Clozapine — MRCPsych Paper B MCQ

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HardSchizophrenia & PsychosisECT Augmentation of ClozapineMRCPsych Paper B

A 35-year-old man with schizophrenia continues to experience prominent delusions and formal thought disorder despite confirmed adherence to clozapine for 6 months at a stable plasma clozapine concentration of 0.48 mg/L. The diagnosis, substance use, physical comorbidity and interacting medicines have been reviewed. He has had an adequate trial of cognitive–behavioural therapy for psychosis and appropriate pharmacological augmentation trials without meaningful benefit. In a specialist treatment-resistant psychosis service, which somatic augmentation may be considered on an individual basis because it has direct trial evidence in clozapine-resistant schizophrenia?

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Correct answer: E — Bilateral electroconvulsive therapy

The best answer is E: bilateral ECT while continuing clozapine. The adequate clozapine exposure, persistence of psychotic symptoms and exclusion of common causes of apparent non-response establish clozapine-resistant schizophrenia. A small randomised study found benefit from bilateral ECT added to clozapine, and systematic-review evidence suggests possible efficacy, although the evidence base is limited and subsequent sham-controlled evidence has been less convincing. Consequently, this is a specialist, individualised option rather than routine treatment. NICE does not recommend ECT for general management of schizophrenia, except for severe catatonia. Repetitive TMS has symptom-specific evidence, particularly for auditory hallucinations, but not equivalent direct evidence for this clozapine-resistant syndrome. tDCS has insufficient evidence, while deep-brain stimulation and vagus nerve stimulation remain experimental.

Reference: Petrides G et al. Electroconvulsive therapy augmentation in clozapine-resistant schizophrenia: a prospective, randomized study. American Journal of Psychiatry. 2015. https://pubmed.ncbi.nlm.nih.gov/25157964/