Electroconvulsive therapy and concurrent psychotropic use

A plan for managing psychotropics during and after electroconvulsive therapy (ECT) should be developed by the patient’s psychiatrist in collaboration with the psychiatrist administering ECT. Some psychotropics may need to be stopped before ECT. The following information is included for reference only, for nonspecialists.

Benzodiazepines raise the seizure threshold and may impair the efficacy of ECT, and should be stopped before ECT.

There are limited benefits to continuing the patient’s antidepressant during ECT; some studies suggest that concurrent antidepressant use may increase the risk of adverse effects. Generally, all antidepressants should be stopped before administering ECT.

Although lithium does not impair the effectiveness of ECT, it may result in severe postictal confusion even at a low blood concentration. The treating psychiatrists should decide on the best approach to managing lithium during ECT.

Continuing an antiepileptic is likely to reduce the efficacy of ECT, prolong the course of ECT and impair cognition. In patients with epilepsy, antiepileptics should not usually be stopped because this increases the risk of seizures. In patients taking antiepileptics for the management of bipolar disorder, antiepileptics are ideally stopped before or early in the course of ECT. If required, antiepileptics can be restarted at the end of the course of ECT.

For psychoses, an antipsychotic should be continued unless clearly ineffective or adversely interacting with ECT (eg seizures related to clozapine use during ECT). Limited evidence suggests that outcomes when combining antipsychotics with ECT are better than for either treatment alone.