The World Journal of Biological Psychiatry, 2009; 10(4): 942Á943
PILAR LOPEZ-GARCIA1, CARLOS CHICLANA1 & RAFAEL GONZALEZ2
1Department of Psychiatry, and 2Department of Neurology, University Hospital, Pamplona, Spain
AbstractThis case report is on the combined use of electroconvulsive treatment (ECT) with a partial dopamine agonist, aripiprazole,in the treatment of a 30-year-old man with chronic and refractory paranoid schizophrenia. The patient had been under highdoses of typical and atypical antipsychotics with a lack of control of the symptoms, characterized by agitation,suspiciousness, and obsessive fears. ECT therapy was started while receiving antipsychotic treatment and aripiprazolewas added to the pharmacological treatment after six sessions of ECT. The convulsive threshold and the seizure durationdid not significantly change after the treatment with aripiprazole was initiated. There was a clinical improvement after thecombined treatment with ECT and aripiprazole and the combination was well tolerated.
Key words: Aripiprazole, ECT, schizophrenia
hospitalization in our unit he had a descompensationwith delusions of persecution, obsessional fears and
In acute and treatment-resistant phases of schizo-
agitation. He was treated in a day hospital regime
phrenia it may be necessary to combine ECT and
but had to be hospitalized four times in the last year.
antipsychotic medications. Although this combina-
At the moment of admission to our psychiatric
tion has been found to be safe and efficacious for
unit, he was receiving treatment with haloperidol (up
several antipsychotics (American Psychiatric Asso-
to 40 mg/day), levomepromacine (up to 100 mg/
ciation 2001), it remains to be demonstrated for
day), clonazepam (up to 6 mg/day) and clotiapine
newer agents. Aripiprazole is a partial dopamine
(up to 40 mg/day). Because of the lack of control of
agonist (Lieberman 2004), clinically approved for
the symptoms with high doses of different antipsy-
schizophrenia. Little is known about the effects of
chotics, 12 sessions of ECT were administered. ECT
aripiprazole on the convulsive threshold and its use
was provided bilaterally with the Thymatron DGX
stimulator three times weekly. The anesthesia con-
We report the combined use of ECT and aripipra-
sisted of propofol 100 mg, succinylcholine 45 mg
zole in a patient with drug-resistant schizophrenia.
and atropine 0.5 mg. Blood pressure, pulse rate and
World J Biol Psychiatry Downloaded from informahealthcare.com by Universidad De Navarra
oxygen saturation were monitored without signifi-
cant incidences. Informed consent was obtainedbefore ECT treatment.
A 30-year-old man with diagnosis of paranoid
For the first six sessions the antipsychotic treat-
schizophrenia (DSM-IV: 295.30) was admitted to
ment with haloperidol and clotiapine was main-
our inpatient unit for agitation, suspiciousness,
tained. From the seventh session on, clotiapine was
impulsions of harm and hypochondriac fears.
stopped and aripiprazole was added to the treatment
He was first diagnosed with schizophrenia at the
starting at an initial dose of 10 mg/day and reaching
age of 20 and has had eight admissions for severe
exacerbations. At the age of 22 he received 11
The average energy dial (DGX) was 26.66% prior
sessions of ECT with clinical response that was
to aripiprazole and 22.5% for the following six
maintained for 6 years when he was also receiving
sessions. Seizure duration was recorded with EEG
clozapine and haloperidol. A year prior to the
and visually. The seizure duration average according
Correspondence: Pilar Lopez-Garcia, MD, PhD, Department of Psychiatry, Clinica Universitaria, Av Pio XII 36, 31008 Pamplona, Spain. Tel: '34 948 255400. Fax: '34 948 296500. E-mail: [email protected]
(Received 16 April 2007; accepted 19 June 2007)
ISSN 1562-2975 print/ISSN 1814-1412 online # 2009 Informa UK Ltd. (Informa Healthcare, Taylor & Francis AS)DOI: 10.3109/15622970701530925
to the EEG recordings was 33.5 s before treatment
mechanism on D2 and 5HT1A receptors (Burris
with aripiprazole and 31.5 s after the onset of aripi-
et al. 2002). No reports have been published on the
prazole. There was a significant clinical improve-
effect of aripiprazole on convulsive threshold and
ment assessed with the PANSS scale after the ECT
seizure induction. Further studies are needed to
treatment (6 points difference in PANSS positive; 10
assess the safety of aripiprazole and newer antipsy-
points difference in PANSS negative and 23 points
of difference in PANSS general psychopathology).
To our knowledge this is the first reported case thathas evaluated the effects of combined treatment with
aripiprazole and ECT. In this case, aripiprazole doesnot interfere on the convulsive threshold, and is well
The authors have no conflict of interest with any
tolerated and clinically effective when ECT is con-
commercial or other associations in connection with
ECTÁantipsychotic combinations might be the
choice treatment option when patients are refractory
to pharmacological treatment. Recent meta-analyses
American Psychiatric Association. 2001. The practice of electro-
have shown the benefit of the combination of ECT
convulsive therapy. Recommendations for treatment, training,
and antipsychotics in the acceleration of treatment
and privileging. Washington, DC: American Psychiatric Asso-
response in the first few weeks of treatment of
schizophrenia (Painuly and Chakrabarti 2006).
Braga JB, Petrides G. 2005. The combined use of electroconvul-
sive therapy and antipsychotics in patients with schizophrenia.
There is limited data on the effects of the
combination of antipsychotics and ECT. Among
Burris KD, Molski TF, Xu C, et al. 2002. Aripiprazole, a novel
atypical agents there have been reports on the safety
antipsychotic, is a high-affinity partial agonist at human
of the combination of ECT and risperidone, olanza-
dopamine D2 receptors. J Pharmacol Exp Ther 302:381Á389.
pine and clozapine (Braga and Petrides 2005).
Lieberman JA. 2004. Dopamine partial agonists: a new class of
Aripiprazole has recently been released as an anti-
Painuly N, Chakrabarti S. 2006. Combined use of electroconvul-
psychotic with a different action mechanism. Instead
sive therapy and antipsychotics in schizophrenia: the Indian
of blocking DA receptors, it exerts a partial agonist
evidence. A review and a meta-analysis. J ECT 22:59Á66.
World J Biol Psychiatry Downloaded from informahealthcare.com by Universidad De Navarra
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The World Journal of Biological Psychiatry, 2009; 10(4): 942Á943
PILAR LOPEZ-GARCIA1, CARLOS CHICLANA1 & RAFAEL GONZALEZ2
1Department of Psychiatry, and 2Department of Neurology, University Hospital, Pamplona, Spain
AbstractThis case report is on the combined use of electroconvulsive treatment (ECT) with a partial dopamine agonist, aripiprazole,in the treatment of a 30-year-old man with chronic and refractory paranoid schizophrenia. The patient had been under highdoses of typical and atypical antipsychotics with a lack of control of the symptoms, characterized by agitation,suspiciousness, and obsessive fears. ECT therapy was started while receiving antipsychotic treatment and aripiprazolewas added to the pharmacological treatment after six sessions of ECT. The convulsive threshold and the seizure durationdid not significantly change after the treatment with aripiprazole was initiated. There was a clinical improvement after thecombined treatment with ECT and aripiprazole and the combination was well tolerated.
to the EEG recordings was 33.5 s before treatment
mechanism on D2 and 5HT1A receptors (Burris
with aripiprazole and 31.5 s after the onset of aripi-
et al. 2002). No reports have been published on the
prazole. There was a significant clinical improve-
effect of aripiprazole on convulsive threshold and
ment assessed with the PANSS scale after the ECT
seizure induction. Further studies are needed to
treatment (6 points difference in PANSS positive; 10
assess the safety of aripiprazole and newer antipsy-
points difference in PANSS negative and 23 points
of difference in PANSS general psychopathology).