L’efficacité de l’électroconvulsivothérapie (ECT) chez les sujets schizophrènes a été établie sur les symptômes hallucinatoires, excitatoires et catatoniques mais peu de données existent sur l’effet à long terme des cures de maintenance (ECT-M).

Nous avons étudié rétrospectivement, dans une population de 19patients, les indications des ECT-M, leur efficacité sur la symptomatologie et sur la qualité de vie, les conditions de rechutes et les traitements médicamenteux associés.

Ces cures sont indiquées lors d’accélération des épisodes aigus en fréquence et en intensité, de résistance, d’inefficacité ou de mauvaise tolérance des traitements médicamenteux, de rechute à l’arrêt des ECT. Tous les patients avaient répondu antérieurement aux ECT en aigu et ont reçu en moyenne 47ECT-M. Tous étaient sous traitement antipsychotique, 30 % recevaient des thymorégulateurs, 10 % des antidépresseurs.

Sous ECT-M, on observe une amélioration nette des symptômes thymiques, anxieux, des troubles du comportement alimentaire et un enkystement ou une disparition du délire ainsi qu’une efficacité sur le risque suicidaire. En revanche, l’ECT-M est peu efficace sur la dissociation et les symptômes négatifs.

Le temps moyen annuel d’hospitalisation et le temps moyen par hospitalisation ont diminué parallèlement à une amélioration de la qualité de vie.

L’ECT-M en adjonction aux antipsychotiques représente donc une réelle opportunité thérapeutique pour les schizophrénies résistantes et il apparaît nécessaire d’en définir plus précisément les modalités et les indications.

Electroconvulsive therapy, a standard treatment in mood disorders, is sometimes also indicated in psychotic disorders, especially in the treatment of refractory schizophrenia. In this instance, maintenance electroconvulsive therapy (M-ECT) can also become a long-term treatment. This paper presents the effects of M-ECT in the treatment of refractory schizophrenia using a retrospective analysis. Previous works showed that electroconvulsive therapy is effective on catatonia, anxiety with somatisation, lack of compliance, opposition, delusions especially with hallucinations and persecution, anorexia, agitation, carelessness, aggressive behaviour and moral pain. It is ineffective on bewilderment, somatic complaints and negative symptoms.

A retrospective analysis of a clinical cohort of patients treated with M-ECT was carried out to determine the specific indications of M-ECT, its effectiveness on clinical symptoms, quality of life, relapse rates and use of medication.

Nineteen patients with DSM-IV diagnosis of paranoid schizophrenia (n=5), schizophrenia with neurotic symptoms (n=3), disorganized schizophrenia (n=1), hebephrenia (n=3) and schizoaffective disorder (n=8), treated in the department of the University Hospital of Sainte-Anne in Paris, received M-ECT between 1991 and 2005. Seven patients are still under this treatment.

Their mean age at the beginning of treatment was 47.5 years with a mean duration of the illness of 24years.

The indication of M-ECT was the increase of acute episodes, an increase of symptoms intensity, the inefficiency or intolerance to pharmacological treatments or an early relapse after ECT discontinuation.

All patients had previously been successfully treated by ECT during an acute episode.

Each patient received an average of 47bilateral M-ECT under general anaesthesia at one to five weeks’ intervals for a mean period of 43months. All of them were also treated by antipsychotics; in addition, 30% received mood stabilizers and 10% antidepressants. The dosage of antidepressants and mood stabilizers was reduced during M-ECT treatment, especially in patients with schizoaffective disorder, probably in relation with the effectiveness of ECT on mood symptoms.

During M-ECT, the mean duration of yearly hospitalizations was decreased by 80% and the mean duration of each hospitalization by 40% with a better ability to take part in activities, sometimes even to return home or go back to work.

There was also a positive effect on quality of life considering the severity of symptoms and the long psychiatric history of these patients. The possibility to go from a full time hospitalization to a day-care facility or to live in a halfway house can be considered as a huge progress.

M-ECT was efficient on mood symptoms, delusions, anorexia, suicidal impetus, anxiety symptoms and increased cooperation and treatment compliance. Efficacy on obsessive compulsive symptoms was less obvious. There was no effect on dissociation and negative symptoms.

Relapses essentially occurred after a stressful life event, a too long interval between the M-ECT sessions or, in 50% of the cases, without any obvious etiology. It required a revision of the M-ECT program and, most of the time, an hospitalization for full ECT treatment.

There is no consensus on the rate and number of M-ECT as it varies from patient to patient and depends upon the extent of the clinical response and side effects. The discontinuation of M-ECT will depend on the clinical symptoms, compliance and tolerance to ECT. As it is the case with ECT treatment for an acute episode, available evidence suggests that treatment with antipsychotics should continue during the maintenance ECT course.

Maintenance electroconvulsive therapy combined with medication may be an efficient alternative to pharmacological treatment alone in refractory schizophrenia. Alternative therapeutical strategies are crucial in this domain, due to the important public health problem it raises.

There are few randomised prospective controlled clinical trials regarding this treatment and further clinical investigations are necessary, notably to define standardized criteria for M-ECT programs.