Successful electroconvulsive therapy and improvement of negative symptoms in refractory schizophrenia with clozapine-induced seizures: a case report.

Clozapine has been found to be superior to traditional neuroleptics in the treatment of refractory schizophrenia (Kane et al. 1988). Because it is associated with rare but life-threatening side effects, including agranulocytosis, myocarditis, aspiration pneumonia, ileus, and weight gain (Nielsen et al. 2013, Young et al. 1998), it is typically only recommended to patients with prominent and persistent psychotic symptoms despite trials of at least two different types of antipsychotic medications (Kreyenbuhl et al. 2010). Among its many side effects, clozapine lowers the seizure threshold. The risk of seizure increases with increasing dosage and rapid dose titration (Devinsky et al. 1991), and additional factors for seizure induction include pre-existing seizure disorders, neurological abnormalities, and the simultaneous use of epileptogenic medications (Toth & Frankenburg 1994). In addition to clozapine, several recent studies and reviews have indicated that electroconvulsive therapy (ECT) may be used to effectively treat patients with treatment-refractory schizophrenia (Kho et al. 2004, Kreyenbuhl et al. 2010). However, earlier reports have shown that most (80%) of the patients had their first spontaneous seizure within 5 weeks of the initiation of ECT treatment (Devinsky & Duchowny 1983). For that reason, ECT in patients with a low seizure threshold is thought to be risky. We describe a case in which ECT was safe and useful for a schizophrenia patient with treatmentrefractory auditory hallucinations who had clozapineinduced seizures.