Acupuncture involves the stimulation of specific acupoints by inserting needles into the skin. Laser acupuncture is essentially the same as needle acupuncture except that laser beams are used instead of needles. Electro-acupuncture uses a pair of needles attached to an electrical device that generates continuous electric pulses that pass from one needle to the other.

What is the evidence for acupuncture for schizophrenia?

Moderate quality evidence suggests general improvement in symptoms of schizophrenia with needle or electro-acupuncture in conjunction with or without, antipsychotic medications compared to antipsychotics alone. Low quality evidence is uncertain of the benefits of laser acupuncture. Review authors state that study quality is very low and all studies were conducted in China, so results may not be applicable to other populations.

September 2020

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Biofeedback is a technique in which information about the person’s body is fed back to the person so that they may be trained to alter the body’s conditions. Physical therapists use biofeedback to help stroke victims regain movement in paralyzed muscles. Other specialists use biofeedback to help their patients cope with pain. It is also commonly used to reduce stress and anxiety, and to encourage relaxation.

What is the evidence for biofeedback?

Low quality evidence from few small studies is unable to determine the benefits of biofeedback for patients with schizophrenia. More research is needed.

September 2020

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In ECT, a seizure is electrically induced after the patient has been given a short-acting anaesthetic and is asleep. Although viewed as controversial, ECT is a well established psychiatric treatment with good evidence to support its effective and safe use. ECT is most often used as a treatment for severe depression that has not responded adequately to other treatments as it has been shown to be more effective than antidepressant medication. It is also used as a first line treatment in depression where an urgent response is required as it works more quickly than medications. While most people with schizophrenia respond adequately to antipsychotic medication, some find it is not completely effective for all of their symptoms. ECT is currently used and is being further evaluated as an additional or alternative treatment for these people and is likely to be most effective for those who have depressive symptoms or have abrupt or recent onset of psychotic symptoms.

What is the evidence for ECT for people with schizophrenia?

Moderate to high quality evidence suggests a small, short-term benefit of ECT compared to sham ECT (placebo) for symptom improvement in people with schizophrenia who are or who are not being treated with antipsychotics. However, there was more memory impairment, headache, and EEG abnormalities with ECT.

Antipsychotics have been found to be more effective than ECT for global improvement, but not mental state, in people who are not necessarily resistant to antipsychotics. In people who are antipsychotic-resistant, moderate to high quality evidence finds a small effect of better mental state with ECT compared to standard care. Lower quality evidence also finds better functioning with ECT.

Moderate to low quality evidence suggests small to medium-sized benefits of ECT alone over psychoanalytic psychotherapy alone for mental state, behaviour, and social functioning six months after treatment, and for global improvement for two years after treatment.

September 2020

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Individuals with serious mental illnesses are more likely to be sedentary than the general population and are consequently at high risk for chronic medical conditions associated with inactivity. Physical activity reduces the risk of these medical conditions, and positive psychological effects have also been reported, including improved quality of life. Exercise also has the potential to alleviate secondary symptoms including depression, low self-esteem and social withdrawal.

What is the evidence for exercise?

Moderate quality evidence finds exercise therapy can improve symptoms, particularly negative symptoms, as well as improving quality of life and functioning. Moderate to low quality evidence suggests exercise therapy can also improve depression, anxiety, weight, and cardiometabolic factors.

Moderate to high quality evidence suggests exercise therapy can improve cognition, particularly working memory, attention, and social cognition. More minutes per week of exercise supervised by a physical activity professional is associated with the greatest benefit for cognition.

Moderate quality evidence finds no significant differences between mindfulness exercise (yoga or tai chi) and non-mindfulness exercise for mental health or social functioning.

September 2020

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tDCS is a non-invasive form of brain stimulation similar to transcranial magnetic stimulation, but instead of using magnets, it uses a low-intensity, constant current applied through scalp electrodes. Generally, anodal stimulation induces an increase of cortical excitability, whereas cathodal stimulation decreases cortical excitability, with effects that last beyond the stimulation period. Dose involves current intensity, duration of stimulation and size of electrodes. While most people with schizophrenia respond adequately to antipsychotic medication, some find it is not completely effective for all of their symptoms. tDCS is currently being investigated as an additional treatment for these people.

What is the evidence for tDCS?

Moderate to low quality evidence finds a large effect of greater improvement in auditory hallucinations with tDCS given twice-daily or over 10 sessions. Over 10 sessions may also improve negative symptoms.

Moderate quality evidence finds a medium-sized effect of greater improvement in working memory, but not other cognitive domains, with prefrontal tDCS.

September 2020

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TMS is a procedure that uses an electromagnetic coil placed over the scalp to stimulate the nerve cells beneath it. In general, low frequency stimulation reduces nerve cell activity and high frequency stimulation increases nerve cell activity. Repetitive TMS (rTMS) has been tested as a possible treatment for schizophrenia. While most people with schizophrenia respond adequately to antipsychotic medication, some find it is not completely effective; rTMS may be of use in these circumstances.

What is the evidence for rTMS?

For positive symptoms, moderate to high quality evidence shows low frequency rTMS (1Hz) applied via continuous stimulation to the left temporo-parietal cortex can reduce the severity of auditory hallucinations in the short term (medium-sized effect). The evidence is uncertain of any benefit over the longer term (>1-month post-treatment), and there was no clear benefit for other positive symptoms.

For negative symptoms, moderate to high quality evidence shows small to medium-sized improvements with rTMS applied to the dorsolateral prefrontal cortex (mostly left side). Negative symptoms were most improved in studies with a pulse frequency of 20 to 50Hz, in those with motor threshold intensity of 110%, and in those with a trial duration over 3 weeks. However, positive symptoms were worsened in studies using these parameters.

For cognition, moderate to high quality evidence indicates a small benefit of rTMS applied to the left DLPFC for <30,000 pulses for improving working memory, with no improvements in other cognitive domains. The effect for working memory may last for up to 3 months.

Moderate to high quality evidence finds a small placebo effect of improved auditory hallucinations with sham rTMS; either non-active sham, or active sham with 45° or 90° tilt away from the stimulation site. There was more headache reported with active rTMS than sham rTMS.

Moderate to low quality evidence finds no clear benefit of rTMS for symptoms in people who are resistant to clozapine, although this analysis consisted of a very small sample, and location and type of application varied across studies.

September 2020

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VNS provides indirect modulation of brain network activity through the stimulation of cranial nerves. Invasive VNS involves surgical implantation of a small pulse generator under the skin which is programmed to deliver long-lasting, intermittent electrical stimulation of the vagus nerve. Non-invasive stimulation involves attaching a stimulator to the outer ear close to the ear canal, which delivers electrical impulses through the skin to the vagus nerve.

What is the evidence for VNS?

Low quality evidence is unable to determine any benefit of non-invasive VNS for the symptoms of schizophrenia. Review authors state that many patients did not adhere to the study protocol, which would have affected the results. No studies were identified that assessed invasive VNS for schizophrenia.

September 2020

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