What is the best course of treatment for a patient with severe mental illness who remains actively psychotic despite undergoing electroconvulsive therapy (ECT)?

Management of Persistent Psychosis During ECT

If a patient remains actively psychotic despite undergoing ECT, optimize the ECT technique by switching from unilateral to bilateral electrode placement, ensure adequate pharmacotherapy with antipsychotics is continued during ECT, and consider extending the treatment course beyond the typical 10-12 sessions while systematically monitoring response. 1

Immediate ECT Optimization Strategy

Electrode Placement Modification

• Switch to bilateral ECT immediately if currently using unilateral placement, as bilateral ECT is specifically indicated for florid psychosis and may be more effective when speed of response is critical 1
• Bilateral electrode placement should be prioritized over unilateral treatment in very ill patients with active psychotic symptoms, despite increased cognitive side effects, because efficacy is more important than reversible cognitive impairment 1
• The cognitive side effects from bilateral ECT are temporary and no longer measurable a few months after the last treatment 1

Treatment Course Extension

• Continue ECT beyond the usual 10-12 treatment course if response is inadequate, as some patients display improvement late in treatment 1
• Reassess response after every 5-6 treatments by carefully evaluating each target symptom and overall functioning 1
• Do not prematurely discontinue ECT - the decision to continue should be based on systematic assessment of psychotic symptoms using standardized rating scales 1

Concurrent Pharmacotherapy Management

Antipsychotic Continuation

• Continue antipsychotic medications during ECT, as the combination of antipsychotics and ECT is well tolerated and may be beneficial 2
• For treatment-resistant psychosis, consider adding or optimizing a neuroleptic agent to the regimen 1
• Olanzapine and mirtazapine can be safely continued during ECT as part of maintenance strategy 3

Medications to Discontinue

• Immediately discontinue benzodiazepines if currently prescribed, as they increase seizure threshold and may prevent adequate therapeutic seizures 4, 2
• Stop carbamazepine if being used, as it has been associated with failure to induce seizures during ECT 4
• Discontinue lithium during ECT when clinically possible due to risk of acute brain syndrome 4, 2

Treatment Frequency Adjustment

• Consider increasing treatment frequency to three times weekly if currently on twice-weekly schedule 1
• Alternatively, if cognitive impairment is significant, maintain twice-weekly administration but extend total treatment duration 1

Diagnostic Reconsideration

Evaluate for Schizoaffective Features

• Reassess whether the patient has schizoaffective disorder rather than pure schizophrenia, as ECT may be more effective when prominent affective symptoms accompany psychosis 1, 5
• Patients with Axis I disorders with prominent affective symptoms may respond better to ECT 1

Consider Catatonic Features

• Evaluate for catatonic symptoms, as catatonia is a specific indication for ECT and may require bilateral electrode placement from the outset 1, 5

Clozapine Consideration for Post-ECT Management

• For treatment-resistant schizophrenia that fails to respond adequately to ECT, clozapine should be considered as it is specifically indicated for severely ill patients with schizophrenia who fail to respond to standard antipsychotic treatment 6
• Clozapine initiation requires baseline ANC of at least 1500/μL and regular monitoring due to risk of severe neutropenia 6
• Start clozapine at 12.5 mg once or twice daily with slow titration to minimize orthostatic hypotension and seizure risk 6

Systematic Monitoring Protocol

• Assess psychotic symptoms before each treatment using standardized rating scales 1
• Monitor for prolonged seizures (>150 seconds), which occur in 0-10% of treatments and may require termination with additional methohexital, diazepam, or lorazepam 1, 4
• Evaluate cognition, mood, and psychosis systematically at treatment intervals and completion 1

Common Pitfalls to Avoid

• Do not assume ECT has failed after only 5-6 treatments - late responders exist and premature discontinuation is a critical error 1
• Do not continue unilateral ECT indefinitely without switching to bilateral placement in actively psychotic patients 1
• Avoid polypharmacy with seizure threshold-elevating medications (benzodiazepines, anticonvulsants) that may sabotage ECT efficacy 4, 2
• Do not discontinue antipsychotics during ECT under the mistaken belief that medications should be stopped - antipsychotics are safe and potentially beneficial during ECT 2

Continuation Strategy After Acute Course

• ECT is effective only in resolving acute illness and will not prevent relapse - a robust maintenance strategy is essential 1
• Consider continuation-maintenance ECT for treatment-resistant psychotic disorders, as this approach has demonstrated effectiveness in preventing relapse 7, 8
• Combine maintenance ECT with optimized antipsychotic pharmacotherapy tailored to the presenting disorder 1