title: Efficacy and safety of treating patients with refractory schizophrenia with antipsychotic medication and adjunctive electroconvulsive therapy: a systematic review and meta-analysis.
abstract: BACKGROUND
  The efficacy and safety of the combined treatment of refractory schizophrenia with antipsychotic medications and electroconvulsive therapy (ECT) remain uncertain.
  
  
  OBJECTIVE
  Conduct systematic review and meta-analysis of available literature in English and Chinese about ECT in the treatment of refractory schizophrenia.
  
  
  METHODS
  English and Chinese databases were searched for studies published prior to May 20, 2015 regarding the efficacy and safety of the combined treatment of refractory schizophrenia with antipsychotic medications and ECT. Two researchers selected and evaluated studies independently using pre-defined criteria. Review Manager 5.3 software was used for data analysis.
  
  
  RESULTS
  A total of 22 randomized control studies, 18 of which were conducted in mainland China, were included in the analysis. Meta-analysis of data from 18 of the 22 studies with a pooled sample of 1394 individuals found that compared to treatment with antipsychotic medications alone, combined treatment with antipsychotic medications and ECT had significantly higher rates of achieving study-specific criteria of 'clinical improvement' (RR=1.25, 95%CI=1.14-1.37). Based on the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) criteria, the quality of evidence for this assessment of efficacy was 'moderate'. However, the proportion of participants who experienced headache during the treatment was significantly higher in the combined treatment group (RR=9.10, 95%CI=3.97-20.86, based on a pooled sample of 517 from 8 studies) and the proportion who experienced memory impairment was also higher in the combined treatment group (RR=6.48, 95%CI=3.54-11.87, based on a pooled sample of 577 from 7 studies). The quality of evidence about these adverse events was rated as 'very low'.
  
  
  CONCLUSIONS
  There are very few high quality randomized controlled clinical trials about the combination of antipsychotic medications and ECT in the treatment of refractory schizophrenia. This meta-analysis found that the combination of antipsychotic medications and ECT could improve psychiatric symptoms in patients with refractory schizophrenia, but the incomplete methodological information provided for most of the studies, publication bias (favoring studies with better outcomes in the combined treatment group), and the low quality of evidence about adverse outcomes, cognitive impairment, and overall functioning raise questions about the validity of the results.
authors.affiliation: Shanghai Key Laboratory of Psychotic Disorders, Shanghai Research Institute of Mental Health, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
authors.forename: Wenzheng
authors.initials: W
authors.lastname: Wang
authors.affiliation: Shanghai Key Laboratory of Psychotic Disorders, Shanghai Research Institute of Mental Health, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
authors.forename: Chengcheng
authors.initials: C
authors.lastname: Pu
authors.affiliation: Shanghai Key Laboratory of Psychotic Disorders, Shanghai Research Institute of Mental Health, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
authors.forename: Jiangling
authors.initials: J
authors.lastname: Jiang
authors.affiliation: Shanghai Key Laboratory of Psychotic Disorders, Shanghai Research Institute of Mental Health, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
authors.forename: Xinyi
authors.initials: X
authors.lastname: Cao
authors.affiliation: Shanghai Key Laboratory of Psychotic Disorders, Shanghai Research Institute of Mental Health, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
authors.forename: Jijun
authors.initials: J
authors.lastname: Wang
authors.affiliation: Shanghai Key Laboratory of Psychotic Disorders, Shanghai Research Institute of Mental Health, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
authors.forename: Min
authors.initials: M
authors.lastname: Zhao
authors.affiliation: Shanghai Key Laboratory of Psychotic Disorders, Shanghai Research Institute of Mental Health, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
authors.forename: Chunbo
authors.initials: C
authors.lastname: Li
keywords: antipsychotic medication; electroconvulsive therapy; meta-analysis; refractory schizophreinia; systematic review