CLINICAL HANDBOOK OF SCHIZOPHRENIA

202 III. SOMATIC TREATMENTquiet, relaxing environment post-ECT usually results in a smooth recovery. Postictaldelirium can be treated with benzodiazepine IV or barbiturate medication. Alternately,increasing or decreasing the dose of succinylcholine and adding a small dose ofmethohexital at the end of the seizure may decrease the incidence of postictal delirium.ECT-Induced Myalgias and HeadachesMyalgias and headaches are two common side effects following ECT treatment. To decreaseand prevent ECT-induced myalgias and headaches, the patient can be premedicatedwith enteric-coated aspirin (650 mg) or acetaminophen (650 mg). In severe cases,ketorolac (30 mg IV) can be administered before the induction of anesthesia. Also,intranasal administration of sumatriptan may be beneficial if the patient develops post-ECT-induced headache despite ketorolac prophylaxis.ECT-Associated Cognitive Side EffectsAnterograde and retrograde amnesia are common cognitive side effects following ECTtreatment. Therefore, memory should be assessed before, during, and after the course ofECT treatment. Treatment should be adjusted according to the severity of the cognitiveside effects. These modifications include changing the electrode placement (i.e., from BTto RUL), modifying the intensity of electrical stimulation from sinus wave to brief pulsestimulus, increasing the time interval between successive treatments, and altering the doseof the anesthetic medications. Typically, following the termination of ECT, cognitive difficultiesresolves.EVIDENCE SUPPORTING INTERVENTIONResearch supporting the use of ECT in schizophrenia treatment has predominantly focusedon its use as an adjunctive treatment to pharmacotherapy. ECT has been shown toincrease the speed of response and efficacy, and ultimately leads to a decrease in both positiveand negative symptoms. However, ECT may only improve positive symptoms andmay in some cases have a minimal effect on negative symptoms.Prior research has indicated that up to 25% of patients with schizophrenia do notadequately benefit from pharmacotherapy alone; thus, ECT is recommended as a treatmentoption. Predictors of response and benefit of ECT in patients with schizophrenia includean acute onset of schizophrenia, short duration of schizophrenia episode and presenceof mood symptoms, delusions or hallucinations, and catatonic features. Negativeindicators of response include long length of episode, older age during illness, previouslyfailed neuroleptic pharmacotherapy, paranoid features, and high prevalence of negativesymptoms.As is the case with affective disorders, ECT is limited in treating schizophrenia due tohigh relapse rates and cognitive side effects. It is uncertain why the relapse rate is high;however, ECT is recommended in combination with pharmacotherapy as a maintenanceand continuation therapy after acute treatment. There is limited research on optimizingECT for schizophrenia, including dosing requirements and electrode placement site. Forexample, one study examined the effects of stimulus intensity during bilateral ECT placementusing one, two, and four times the seizure threshold. The investigators concludedthat clinical response time was positively related to the degree of stimulus dosing