Psychotropic Medications during ECT

 

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A careful review of medication is essential before starting a course of ECT. Existing medications

for medical illness can usually be continued throughout the ECT course and given one hour before the ECT with sips of water, or after the treatment when the patient is fully awake. Diabetic patients should be given priority if several patients receive ECT on the same day. Insulin and hypoglycemic agents are usually given after the treatment. Medical consultations may be requested for patients with poorly-controlled blood sugars or with respiratory or cardiovascular illnesses. Consideration should also be given whether to continue psychotropic medications throughout an ECT course. As a general rule, it is favourable to discontinue as many medications as possible to decrease the risk of delirium and minimize cognitive side effects. This is particularly applicable to those bearing anticholinergic effects. On the other hand, in bipolar patients, it may be necessary to maintain mood stabilizers throughout the ECT course; for example, to reduce the risk of iatrogenically shifting a patient’s depressed state into mania. No substantial evidence currently exists to support that the combined use of ECT and medications improves the efficacy of ECT in symptom reduction.江西省精神病医院精神科朱健民

Antidepressant Medications

■ Selective Serotonin Reuptake Inhibitors (SSRIs)SSRIs are commonly administered throughout the ECT course. Conflicting reports exist about the safety of this; some point towards a possible improved result when combined with ECT, some report no improved results, and others suggest both shortened seizure length and prolonged seizure length. Discontinuing SSRIs before ECT may be recommended for patients at higher risk of post-ECT delirium (i.e., those on multiple medications, the elderly, or those with co-existent dementia). If SSRIs are continued, the anesthetist should be informed and alerted to the possible risk of a prolonged seizure.

■ Monoamine Oxidase Inhibitors (MAOIs) Selective MAOIs (e.g., moclobemide) are likely safe to continue, although little data exists on their effects. Nonselective MAOIs (e.g., phenelzine, tranylcypromine) are also likely safe to continue. If hypotension occurs during the ECT, indirect-acting vasopressors should be avoided and neosynephrine used instead. In such a circumstance, an anesthesia consultation should be done before the first ECT.

■ Tricyclic Antidepressants (TCAs)

These are likely safe to continue. TCAs with stronger anticholinergic side effect(e.g.,amitriptyline,imipramine, trimipramine, clomipramine) have increased risk of creating post-ECT confusion, and should be discontinued if possible.

■ Bupropion Hydrochloride

No data exists about the safety of bupropion (Wellbutrin) during ECT. Due to case reports of spontaneous seizures, it should likely be discontinued.

■ Others (e.g.,Venlafaxine,Nefazodone,Trazodone) No data exists.

Mood Stabilizers

■ Lithium Carbonate

Controversy about the use of lithium during ECT centres on reports of increased risk for delirium,

prolonged seizures, and possible decreased seizure thresholds. Generally lithium is well-tolerated

at lower doses, and may have to be continued in patients with refractory mood disorders. Lithium

should be held the night before and the morning of ECT and given post-ECT. Lithium carbonate

levels should be done before ECT.

■ Anticonvulsant Agents (Carbamazepine,Valproic Acid,Gabapentin, Lamotrigine,Phenytoin,Topiramate)Again, clear guidelines do not exist, but reports point towards decreased seizure time, higher seizure thresholds, and possible decreased efficacy of ECT for improving mood symptom when they are used concomitantly with ECT. They are generally well tolerated, however. If they are being used as mood stabilizers, doses should be held the night before and the morning of ECT.

■ Antipsychotic Agents

Traditional antipsychotics lower seizure threshold, but as with TCAs, may increase post-ECT delirium if they hold a stronger anticholinergic profile (e.g., chlorpromazine, thioridazine, methotrimeprazine, and fluphenazine). Little information exists about the safety or efficacy of combining ECT with novel antipsychotics. Reserpine has been associated with death when used during ECT and should therefore not be used.

■ Benzodiazepines

Benzodiazepines are commonly used in a variety of psychiatric illnesses, and have a major effect on ECT. They clearly increase seizure threshold. Many reports also define their role in lessening seizure efficacy for mood symptoms. If the indications for benzodiazepine use cannot be managed by other substitute agents (e.g., sedatives, antipsychotic agents), then

■ Benzodiazepines with medium half-life (i.e. 8 hours) should be used, and held the morning of ECT.

■ IV Flumazenil can be used in the treatment room if it is clear the benzodiazepine impacts upon ECT efficacy. IV Midazolam should then be given in the PAR room to ensure withdrawal symptoms do not occur.