Resolution of Persistent Auditory Verbal Hallucinations after Long-term Electroconvulsive Therapy Maintenance: A Case Report of a Patient with Clozapine-resistant Schizophrenia

Abstract

A 32-year-old woman with schizophrenia and persistent auditory verbal hallucinations (AVHs), which caused continuous suicidal thoughts and depression, was treated with electroconvulsive therapy (ECT) of an acute course followed by maintenance ECT (M-ECT) augmented onto clozapine for 7 years. Although the general psychopathology and AVHs initially reduced slightly with ECT and clozapine, her AVHs and suicidal thoughts did not decrease subjectively. When 3 years of M-ECT, her voices declined sharply, and improvement was maintained for 2 years thereafter. A total 91 ECT sessions were performed. The daily clozapine dose was decreased from 325 to 200 mg and plasma levels remained higher than 350 ng/ml; there were no noticeable cognitive side effects. In summary, we report a case showing a sudden sharp reduction in persistent AVHs after 3 years of long-term M-ECT.

Keywords: Auditory verbal hallucinations; Clozapine; Maintenance electroconvulsive therapy; Schizophrenia.

Fig. 1

Changes in Hamilton Program for Schizophrenia Voices Questionnaire (HPSVQ) scores during combined electroconvulsive therapy (ECT) and clozapine treatment of a patient with treatment- resistant schizophrenia The vertical lines at the bottom of the graph indicate the dates of ECT. The Kendall’s tau (pvalue) for total, emotional factor, and physical factor HPSVQ scores was −0.310 (0.0242), −0.395 (0.0059), and −0.130 (0.404), respectively, when M-ECT data (after August of 2014) were analyzed. The total and positive syndrome, negative syndrome, and general psychopathology scores on the PANSS were −0.0883 (p = 0.584), −0.317 (p = 0.0510), 0.381 (p = 0.0190), and −0.128 (p = 0.428), respectively. The pvalue indicates the significance value whether Kendall’s tau was zero or not. M-ECT, maintenance ECT; PANSS, Positive and Negative Syndrome Scale.