The Problem Schizophrenic : Clozapine or ECT?

Sir, Clozapine was introduced in India with much fanfare in May 1995. Presently, there are three accepted indications for clozapine therapy: treatment resistant schizophrenia, intolerance to neuroleptic drugs and tardive dyskinesia (Marder and Van Putten, 1988). The pharmaceutical industry is a powerful lobby and it is therefore likely that clozapine will be enthusiastically used for these indications. Pressure will also come from families of patients who have been exposed to publicity about clozapine in the lay press. But is clozapine really the treatment method of choice for the indications specified? In view of the costs associated with clozapine therapy and the unavoidable blood monitoring thereby necessitated, and in view of the nearly 1% risk for agranulocytosis, I suggest not. Consider: the single most important report on which the present status of clozapine in psychopharmacology is based in the Kane et al. (1988) study which addressed rigorously defined treatment resistant schizophrenia. However, Kane et al. did not employ non-responsiveness to electroconvulsive therapy (ECT) in their definition of treatment resistance; social compulsions were no doubt responsible, for ECT is not a popular treatment in the USA. Infact, none of the published studies on clozapine recruited patients who fail a course of ECT. In India, no non-medical compulsions restrict the application of ECT to the treatment-resistant schizophrenic. That ECT is effective in such patients is well known (Friedl, 1986: Gujavarty et al., 1987: Andrade, 1993) ECT, of course is also a convenient treatment for patients intolerant to neuroloptic drugs. And, ECT may also be therapeutic for tardive dyskinesia (Andrade, 1991). Finaly, there has been a resurgence of interest in maintenance ECT (Kellner, 1994), and it is likely that continuation and maintenance (outpatient) ECT administered once in 2-4 weeks may resolve the problem of maintenance medication in such patients (Andrade, 1995). ECT does not have a lobby to promote its optimal use: nevertheless, it is hoped that clini-cians in India will consider ECT-nonresponsiveness as an additional prerequisite for patients who are to receive clozapine. the treatment resistant schizophrenic: A double-blind comparison with chlorpromazine.