Can mECT be Effective for Treatment-Resistant Schizophrenia? A Case Report

Corresponding Author:

Kaoru Odagaki
Department of Psychiatry, Iryouhoujin Keieikai Yashio Hospital, Tsurugasone1089, Yashio City, Saitama prefecture, Japan
E-mail: [email protected]

Received date: 19-Jun-2025, Manuscript No. NPY-24-166994; Editor assigned: 21-Jun-2025, PreQC No. NPY-24-166994 (PQ); Reviewed date: 07-Jul-2025, QC No. NPY-24-166994; Revised date: 13-Mar-2026, Manuscrfipt No. NPY-24-166994 (R); Published date: 21-Mar-2026, DOI: 10.37532/1758-2008.2026.17(1).792

Abstract

The modified Electroconvulsive Therapy (mECT) is considered to be effective in several research papers but there seems to be room for debate about whether it is truly effective, and doubts still remain. Also there is a report that approximately only 30-60% of treatmentresistant schizophrenia benefit from clozapine monotherapy or are partial responders and the choice of antipsychotics varies case by case. I would like to report a case of treatmentresistant and refractory schizophrenia that I have encountered. The patient was a 35 years old female when she was hospitalized to our hospital.

Keywords

Treatment-resistant schizophrenia; mECT; Antipsychotics; Hallucinations; Delusions

Introduction

The patient was born in Tokyo as the eldest of three siblings. She advanced to a private university in Tokyo, graduating from the Faculty of Literature. After employment at a general company, she began experiencing persecutory delusions, believing that “colleagues are speaking ill of me,” which made it difficult for her to sustain long-term employment.

Case Presentation

• Pre-hospital course

In January 2017, the patient visited Clinic A in Kanda under suspicion of developmental disorder. However, she discontinued follow- up in January 2021. Around 2018, she began expressing delusions of electromagnetic wave attacks, displaying odd behaviors such as covering her bed in aluminum foil. In February 2022, under command hallucinations, she set fire to her sleeping mother’s futon and was arrested for attempted murder. She was not prosecuted and was admitted under involuntary hospitalization to Hospital B from March 7 to June 15 of the same year. After discharge, she resumed outpatient treatment at Clinic A but experienced a relapse. Due to fear from hallucinations, she voluntarily requested hospitalization and was admitted to Hospital B on September 3. As the patient’s father was burdened with caregiving responsibilities for her mother, he requested transfer to a hospital closer to home. Accordingly, on October 11, 2023, the patient was transferred to our hospital. As the patient demonstrated some degree of insight, the Designated Psychiatrist, after oral and written explanation, obtained informed consent and the patient was admitted under voluntary hospitalization [1-7].

Despite admission, persistent auditory hallucinations such as “I’ll kill you” were reported. Considering treatment-resistant hallucinations, risperidone was replaced with blonanserin and augmented with aripiprazole. When both drugs were titrated to 24 mg, notable improvement was observed, and hallucinations and nightmares disappeared.

• Condition at admission

The patient’s condition fluctuated, but upon transfer to another ward on May 31, 2024, she experienced acute exacerbation possibly due to environmental change. By June 1, she developed paranoid delusions, stating, “The cook is poisoning me,” and began refusing food and medication. She was promptly returned to the original ward. Emergency intramuscular levomepromazine was administered but was ineffective. Her condition deteriorated further, presenting with disorganized speech, intense persecutory delusions, auditory hallucinations, agitation, and psychomotor excitement, with high risk of violent behavior. She lacked insight and judgment, and strongly resisted care. She exhibited frequent soliloquy and made threatening remarks such as “I’ll kill you” toward staff. The designated psychiatrist diagnosed an acute exacerbation of schizophrenia and deemed hospitalization and physical restraint necessary. However, due to lack of insight, informed consent could not be obtained. Therefore, after oral explanation to her father and obtaining his consent, the hospitalization was changed to involuntary hospitalization under medical protection on June 5. The patient was orally and in writing informed of this change.

• Course during hospitalization

Upon examination by the Designated Psychiatrist, strong persecutory delusions, auditory hallucinations, active soliloquy, and psychomotor agitation were confirmed. The patient was informed orally and in writing of the rationale, and full-body restraint was initiated at 16:15 on June 5. At the patient’s strong request, nighttime medicationsnitrazepam 10 mg, trazodone 50 mg, and senna 24 mgwere discontinued. Though stating “the medicine is poison,” she reluctantly continued taking daytime medication. Daily intramuscular haloperidol 5 mg led to gradual calming of irritability and agitation. On June 10 at 10:15, four-limb restraint was lifted, maintaining only trunk restraint. However, due to self- removal of IV lines and urinary catheter and subsequent nighttime restlessness, two-limb and trunk restraint was reinstated on June 13 at 15:50. Gradually, the patient resumed oral intake and did not refuse medication. However, upon release of upper limb restraint, she attempted to slip through the belts, stood on the bed, and exhibited odd behaviors such as shouting in the hallway, “This is unlawful confinement! Release me!”

Recognizing the importance of psychoeducation, repeated explanations were provided regarding the necessity of medication and efforts were made to develop insight. Once the absence of hyperactivity, verbal aggression, or risk of harm to others was confirmed, physical restraint was discontinued on June 27 at 10:30 in consultation with the designated psychiatrist, and this was recorded immediately.

Medications were gradually tapered at the patient’s request; ultimately, blonanserin was reduced to 16 mg and aripiprazole to 12 mg. However, the patient continued to experience instability, including restlessness, hyperactivity, food and medication refusal, and required renewed restraint from September 5 at 14:30. As the patient was diagnosed with treatment-resistant schizophrenia, and due to the recurring refusal of treatment stemming from lack of insight, the limitations of treatment at our facility were recognized. Transfer was arranged to Hospital C for modified Electroconvulsive Therapy (mECT), and the patient was transferred on September 25. The discharge notification was promptly submitted to the prefectural governor via the public health center.

Discussion

This case represents treatment-resistant schizophrenia. Symptomatic or organic psychiatric disorders were ruled out via head CT and blood tests. The symptomatic profile clearly aligns with schizophrenia. The patient exhibited recurrent exacerbations and remissions over a prolonged hospitalization. After resuming medication, positive symptoms improved rapidly, but lack of insight led to repeated relapses due to non-adherence. This episode also highlighted the patient’s vulnerability to stressher condition worsened acutely following a ward transfer. Previous trials with olanzapine and risperidone had little effect. However, titration of blonanserin and aripiprazole to near-maximal doses (24 mg) resulted in resolution of hallucinations and delusions. Monthly intramuscular decanoate haloperidol (100 mg) also proved beneficial.

At discharge, the patient had developed some insight, albeit limited. Ongoing education and improved understanding of her illness and the importance of relapse prevention are crucial. As a relatively young individual, her long-term goal remains a decrease in disease symptoms and reintegration into society [5-7]. With stabilization of symptoms, a gradual return to home life through trial leaves and overnight stays appears feasible (Table 1).

Table 1: Time table with antipsychotic doses.

Conclusion

This case report underscores the complex and challenging nature of Treatment-Resistant Schizophrenia (TRS). Despite trials with various antipsychotics and a period of symptom improvement with blonanserin and aripiprazole, this patient experienced recurrent relapses, largely driven by a lack of insight and subsequent non-adherence to medication. This case demonstrates that even with optimized pharmacological interventions, some patients with TRS may require more intensive treatments like mECT to achieve symptomatic control and improve insight. Ongoing psychoeducation and a focus on longterm relapse prevention, with the goal of social reintegration, remain critical for such patients.

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