ELECTROCONVULSIVE THERAPY AS AN AUGMENTATION STRATEGY IN CLOZAPINE-RESISTANT SCHIZOPHRENIA

Aims: This narrative review evaluates the efficacy, tolerability, and clinical applicability of electroconvulsive therapy (ECT) as an augmentation strategy in clozapine-resistant schizophrenia (CRS), a particularly severe subtype of treatment-resistant schizophrenia (TRS) unresponsive to clozapine. It also aims to summarize current evidence from clinical studies and highlight unresolved challenges in the use of ECT for this population. Methods: A comprehensive literature search was conducted in PubMed, Cochrane Library, Embase, and Web of Science for English-language publications from 2014 to 2024. The search focused on studies addressing clozapine-resistant schizophrenia and electroconvulsive therapy. Inclusion criteria comprised clinical relevance, focus on ECT as augmentation, and sufficient methodological quality. A total of 191 publications, including clinical studies, reviews, and meta-analyses, were selected and synthesized to evaluate efficacy, tolerability, and clinical application. Results: The majority of studies suggest that ECT augmentation improves positive symptoms and overall clinical outcomes in patients with clozapine-resistant schizophrenia. Reported adverse effects are typically mild and transient, including headache and short-term cognitive impairment. Maintenance and continuation ECT (M/C-ECT) appear beneficial in sustaining remission and reducing relapse risk. Nevertheless, the overall strength of evidence is limited by methodological heterogeneity, small sample sizes, and the scarcity of randomized controlled trials. Conclusions: ECT represents a promising adjunctive intervention for clozapine-resistant schizophrenia, particularly in cases unresponsive to pharmacological strategies alone. Despite encouraging clinical data, its routine implementation is constrained by limited high-quality evidence. Further well-designed trials are needed to define patient selection criteria, optimal treatment protocols, and long-term outcomes, and to support the integration of ECT into standardized treatment guidelines.