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Ali M, Malathesh BC, Chatterjee SS, Das S, Pokhrel P, Hernandez MET, Murnin JC. Delirium with Concurrent Use of Lithium and ECT and the Safety Implications: Case Reports and Review of the Literature. Case Rep Psychiatry 2023; 2023:9117292. [PMID: 37200983 PMCID: PMC10188255 DOI: 10.1155/2023/9117292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 04/03/2023] [Accepted: 04/21/2023] [Indexed: 05/20/2023] Open
Abstract
Using electroconvulsive treatment and lithium together to treat acute manic episodes is common, but the effects of combining these therapies vary according to the literature. Some studies have found severe adverse side effects, while others have found the combination of both medications safe and helpful. To investigate potential adverse side effects, this study reports on two cases where bipolar affective disorder patients developed delirium after receiving electroconvulsive therapy and lithium concurrently. The delirium was attributed only to the combined administration of these medicines after ruling out other potential causes. Additionally, alterations in blood-brain barrier permeability, such as those caused by electroconvulsive therapy and age, increased the likelihood of delirium. As a result, caution should be taken when using this combination of medicines, especially in those predisposed to delirium. This study established links between these medications and adverse effects, such as delirium. Further research is necessary to determine the efficacy and risks of combining these medications, establish causality, and develop prevention strategies.
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Affiliation(s)
- Mustafa Ali
- Government Medical College, Jammu and Kashmir, India
| | | | | | | | | | | | - John C. Murnin
- Burrell College of Osteopathic Medicine, New Mexico, USA
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Martins-Ascencao R, Rodrigues-Silva N, Trovão N. Absence of Longer Reorientation Times in Patients Undergoing Electroconvulsive Therapy and Concomitant Treatment with Lithium. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE 2021; 19:695-704. [PMID: 34690124 PMCID: PMC8553532 DOI: 10.9758/cpn.2021.19.4.695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 10/06/2020] [Accepted: 11/13/2020] [Indexed: 11/18/2022]
Abstract
Objective Lithium is a drug of choice in the treatment of bipolar disorder and refractory depressive disorders. However, previous research suggests lithium has a negative cognitive impact in recovery from electroconvulsive therapy (ECT) and a higher risk of delirium, so patients are often required to stop taking lithium before ECT, despite risk of relapse. We studied the cognitive impact of serum lithium levels in patients undergoing ECT. Methods This was an observational prospective study. Serum lithium levels, thyroid and biochemical parameters were measured prior to each ECT session. Time elapsed from the anesthetic induction to the electrical stimulus and then to the patients’ reorientation was recorded, as well as the motor seizure duration and electroencephalogram (EEG) seizure duration. A statistical analysis using a linear mixed model was run while adjusting for confounding factors. Results Ten participants underwent a total of 86 ECT sessions (41% right unilateral ultrabrief pulse, and 59% bilateral brief pulse). A negative interaction between lithium levels and reorientation time was found among those doing bilateral brief pulse ECT. No association was observed in patients doing unilateral ultrabrief pulse ECT. No significant relationship was observed between lithium and both motor and EEG-assessed seizure duration. Conclusion This study suggests that low to moderate serum lithium levels (< 0.7 mmol/L) might have no harmful cognitive effects in patients under right unilateral ultrabrief pulse and bilateral brief pulse ECT.
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Affiliation(s)
- Ricardo Martins-Ascencao
- Medical Department of the Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal
| | - Nuno Rodrigues-Silva
- Medical Department of the Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal.,ECT Unit, Trofa Saúde Senhor do Bonfim Hospital, Vila do Conde, Portugal.,Conde Ferreira Healthcare Center, Porto, Portugal
| | - Nuno Trovão
- Medical Department of the Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal.,Department of Psychiatry and Mental Health, Cova da Beira University Hospital Center, Covilhã, Portugal
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Soehle M, Bochem J, Kayser S, Weyerhäuser J, Valero R. Challenges and pitfalls in anesthesia for electroconvulsive therapy. Best Pract Res Clin Anaesthesiol 2020; 35:181-189. [PMID: 34030803 DOI: 10.1016/j.bpa.2020.12.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 12/11/2020] [Accepted: 12/19/2020] [Indexed: 12/28/2022]
Abstract
Electroconvulsive therapy (ECT) refers to the application of electricity to the patients' scalp to treat psychiatric disorders, most notably, treatment-resistant depression. It is a safe, effective, and evidence-based therapy that is performed with general anesthesia. Muscle relaxation is used to prevent injuries related to the tonic-clonic seizure caused by ECT. Hypnotics are administered to induce amnesia and unconsciousness, so that, patients do not experience the period of muscle relaxation, while the generalized seizure is left unnoticed. For the anesthesiologist, ECT is associated with the challenges and pitfalls that are related to informed consent, social acceptance of ECT, airway management (especially in COVID-19 patients), and the interaction between ventilation and anesthetics from one viewpoint, and seizure induction and maintenance from another. The exact mode of action of the therapy is as unknown as the optimal choice or combination of anesthetics used.
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Affiliation(s)
- Martin Soehle
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany.
| | - Janina Bochem
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Sarah Kayser
- Department of Psychiatry, Psychotherapy and Psychosomatic Medicine, Rheinhessen-Fachklinik, Alzey, Germany
| | - Jan Weyerhäuser
- Department of Psychiatry, Psychotherapy and Psychosomatic Medicine, Rheinhessen-Fachklinik, Alzey, Germany
| | - Ricard Valero
- Department of Anaesthesiology, Hospital Clínic de Barcelona, IDIBAPS, CIBERSAM. University of Barcelona, Barcelona, Spain
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Janjua AU, Dhingra AL, Greenberg R, McDonald WM. The Efficacy and Safety of Concomitant Psychotropic Medication and Electroconvulsive Therapy (ECT). CNS Drugs 2020; 34:509-520. [PMID: 32342484 DOI: 10.1007/s40263-020-00729-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Electroconvulsive therapy (ECT) is an effective treatment for severe psychiatric disorders. Patients referred to ECT are often taking multiple medications, many of which can potentially affect the safety and efficacy of their course of ECT. This review evaluates the impact of a variety of psychotropic medications often used in conjunction with ECT and examines strategies to optimize their management. The review encompasses mood stabilizers, antidepressants, benzodiazepines, antiepileptics, antipsychotics, and other commonly used psychotropics.
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Affiliation(s)
- A Umair Janjua
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, 12 Executive Park Drive, NE, Atlanta, GA, 30329, USA.
| | - Amitha L Dhingra
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, 12 Executive Park Drive, NE, Atlanta, GA, 30329, USA
| | | | - William M McDonald
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, 12 Executive Park Drive, NE, Atlanta, GA, 30329, USA
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Tsujii T, Uchida T, Suzuki T, Mimura M, Hirano J, Uchida H. Factors Associated With Delirium Following Electroconvulsive Therapy: A Systematic Review. J ECT 2019; 35:279-287. [PMID: 31764452 DOI: 10.1097/yct.0000000000000606] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Delirium following electroconvulsive therapy (ECT) has been a clinical challenge, which, however, has not been investigated through a systematic literature review. The objective of this study was to systematically synthesize available evidence regarding factors associated with post-ECT delirium. METHODS We conducted a systematic literature search for any type of original investigations that reported risk factors of post-ECT delirium, using PubMed. RESULTS The literature search identified 43 relevant articles. One study found an association between catatonic feature and increased risk of postictal delirium. Five studies reported that the presence of cerebrovascular disease, Parkinson disease, or dementia was related to higher incidence of post-ECT delirium. Incidence of post-ECT course delirium was increased with bitemporal stimulation (3 studies). One study showed that ultrabrief pulse ECT reduced reorientation time following seizure compared with brief pulse ECT. High stimulus intensity resulted in more prolonged reorientation time after ECT than lower stimulus intensity (2 studies). Longer seizure length was significantly associated with post-ECT delirium in 1 study. Eight studies that examined postictal delirium in association with medications used, including lithium, did not show any consistent finding in their relationships. Four studies showed decreased incidence of postictal delirium in those receiving dexmedetomidine. CONCLUSIONS Limited evidence suggests that catatonic feature, cerebrovascular disease, Parkinson disease, dementia, bitemporal electrode placement, high stimulus intensity, or longer seizure length are associated with an increased risk of post-ECT delirium. Moreover, dexmedetomidine and ultrabrief pulse ECT seem to have preventive effects of post-ECT delirium.
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Affiliation(s)
- Takashi Tsujii
- From the Department of Neuropsychiatry, Keio University School of Medicine, Tokyo
- Department of Psychiatry, Asaka Hospital, Fukushima
| | - Takahito Uchida
- From the Department of Neuropsychiatry, Keio University School of Medicine, Tokyo
| | - Takefumi Suzuki
- Department of Neuropsychiatry and Clinical Ethics, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Masaru Mimura
- From the Department of Neuropsychiatry, Keio University School of Medicine, Tokyo
| | - Jinichi Hirano
- From the Department of Neuropsychiatry, Keio University School of Medicine, Tokyo
| | - Hiroyuki Uchida
- From the Department of Neuropsychiatry, Keio University School of Medicine, Tokyo
- Geriatric Psychiatry Division, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
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Patel RS, Bachu A, Youssef NA. Combination of lithium and electroconvulsive therapy (ECT) is associated with higher odds of delirium and cognitive problems in a large national sample across the United States. Brain Stimul 2019; 13:15-19. [PMID: 31492631 DOI: 10.1016/j.brs.2019.08.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 08/06/2019] [Accepted: 08/20/2019] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND Lithium is a helpful adjunct to patients undergoing ECT. However, only case reports and limited data suggest increase risk of delirium. Thus, this continues to be a controversial issue. OBJECTIVE In this study, we examine 1) The association and odds of delirium and cognitive problems with ECT and lithium (ECT + Li) combination compared to ECT alone, 2) If positively associated, would this association vary by both type of mood episode and type of disorder? METHODS A national sample of 64,728 adult psychiatric inpatients across the US (identified from a total data of about 70 million total discharges annually) was analyzed using linear-by-linear association and logistic regression to assess the odds ratio (OR) for delirium and cognitive impairment for those treated with lithium (N = 158), ECT (N = 64148), or ECT + Li (N = 422) after adjusting for demographics and psychiatric diagnoses. RESULTS The prevalence of delirium was higher in the ECT + Lithium group (5.7%) vs. ECT only (0.6%) or lithium only groups (0%). Patients managed with ECT + Lithium have 11.7-fold higher odds (95% CI 7.55-17.99, P < 0.001) of delirium compared to ECT alone. In the ECT + Li group, delirium prevalence was 7.8% in unipolar depression, 3.4% in bipolar depressed, 0% in bipolar mania. CONCLUSION These results are surprising given the fading concern about delirium association with ECT + lithium combination. The high odds in the combination group warrant clinical caution, use of lower lithium doses (if combinations cannot be avoided), and vigilance regarding early signs of delirium. These results warrant replication in future studies.
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Affiliation(s)
| | - Anil Bachu
- Department of Psychiatry, Allegheny Health Network, Pittsburgh, PA, USA
| | - Nagy A Youssef
- Department of Psychiatry and Health Behavior, Medical College of Georgia at Augusta University, Augusta, GA, USA; Academic Affairs, Medical College of Georgia at Augusta University, Augusta, GA, USA; Charlie Norwood VA Medical Center, Augusta, GA, USA
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Delayed Onset and Prolonged ECT-Related Delirium. Case Rep Psychiatry 2013; 2013:840425. [PMID: 24078892 PMCID: PMC3776541 DOI: 10.1155/2013/840425] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Accepted: 08/04/2013] [Indexed: 11/17/2022] Open
Abstract
Electroconvulsive therapy (ECT) is effective in the treatment of depression. Delayed post-ECT delirium is rare but can occur in a small subset of patients with risk factors and in most cases resolves with the use of psychotropic medications. We report a unique presentation of a patient who developed a delayed post-ECT delirium with fecal incontinence that commenced 24 hours after the administration of ECT. The condition resolved spontaneously after 48 hours without the use of psychotropic medications.
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Thirthalli J, Harish T, Gangadhar BN. A prospective comparative study of interaction between lithium and modified electroconvulsive therapy. World J Biol Psychiatry 2011; 12:149-55. [PMID: 20645670 DOI: 10.3109/15622975.2010.504860] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES To compare patients on lithium and those not on lithium with regard to adverse effects while receiving ECT. METHODS Inpatients with schizophrenia, non-organic psychosis, mania and depression, who were prescribed ECTs either on (n=27) or not (n=28) on lithium were studied. Clinicians blind to lithium-status recorded seizure parameters, interaction with succinyl choline, cardiovascular response, recovery from ECT and immediate post-ECT complications. RESULTS The lithium group showed no significant difference in terms of seizure variables, apnea time, and recovery from anaesthesia when compared to the non-lithium group. Average maximum heart rate, average maximum systolic blood pressure and average maximum rate pressure product were significantly lower in patients who had combined lithium and ECT. In lithium patients the average time to post-ECT recovery was directly correlated with serum lithium level. CONCLUSIONS Though concurrent lithium is by and large safe during ECT, it benefits to maintain serum lithium level at lower end of therapeutic range. However, the findings can be applied to relatively young patients with no risk factors for ECT-complications.
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Affiliation(s)
- Jagadisha Thirthalli
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, Bangalore, India.
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Dolenc TJ, Rasmussen KG. The safety of electroconvulsive therapy and lithium in combination: a case series and review of the literature. J ECT 2005; 21:165-70. [PMID: 16127306 DOI: 10.1097/01.yct.0000174383.96517.77] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Early reports cautioned against the combination of lithium and electroconvulsive therapy (ECT), citing risk of excessive cognitive disturbance, prolonged apnea, and spontaneous seizures. However, recent case series with larger numbers of patients indicate that the combination may be used safely and with optimal efficacy in certain clinical circumstances. In this report, we describe 12 patients in whom the combination of lithium and ECT was deemed safe. We also provide a comprehensive review of published literature and provide detailed recommendations for clinical practice.
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Affiliation(s)
- Tamara J Dolenc
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota 55905, USA
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Jha AK, Stein GS, Fenwick P. Negative interaction between lithium and electroconvulsive therapy--a case-control study. Br J Psychiatry 1996; 168:241-3. [PMID: 8837918 DOI: 10.1192/bjp.168.2.241] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Concurrent use of lithium and ECT is suspected to increase neurotoxicity. METHOD A retrospective case-control study over an eight-year period was conducted to investigate the adverse effects of a combined lithium/ECT treatment. Thirty-one subjects with combined lithium/ECT treatment were compared with a control group (ECT only) of 135 cases matched for age and sex. RESULTS Most cases in both groups had no adverse effects. Three (10%) study group subjects and 15 (11%) controls experienced brief delirium. Three controls and none of the subjects developed a prolonged confusion. There were no significant differences in the profile of other adverse effects between the two groups. CONCLUSION Prescription of lithium together with ECT was not associated with higher frequency of adverse effects.
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Affiliation(s)
- A K Jha
- Department of Psychiatry, Farnborough Hospital, Kent
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