What medications should be stopped prior to Electroconvulsive Therapy (ECT)?

Medications to Discontinue Prior to Electroconvulsive Therapy (ECT)

Whenever possible, it is recommended to discontinue all medications, particularly psychotropics, while a patient is receiving ECT to minimize potential adverse interactions and complications. 1

High Priority Medications to Discontinue

• Lithium: Should be avoided during ECT when clinically possible due to reports of acute brain syndrome when used concurrently with ECT 1, 2

• Trazodone: Should be discontinued due to reported adverse side effects, specifically prolonged seizures during ECT 1, 3

• Carbamazepine: Should be discontinued as it has been associated with failure to induce seizures during ECT 1

• Theophylline: Should be discontinued as it is known to prolong seizure duration at both therapeutic and toxic levels 1, 3

• Benzodiazepines: Should be discontinued as they may increase seizure threshold, potentially making it difficult to induce therapeutic seizures 1, 4

Management Algorithm for Medication Discontinuation

1. Assess medication regimen: Review all current medications for potential interactions with ECT 1

2. Prioritize discontinuation:

   • First tier (highest risk): Lithium, trazodone, carbamazepine, theophylline 1, 3
   • Second tier: Benzodiazepines, other anticonvulsants 1, 4
   • Third tier: Other psychotropics when possible 1

3. Timing considerations:

   • Allow sufficient washout period based on medication half-life 5
   • For lithium, consider gradual tapering to avoid withdrawal symptoms 2

4. Special populations:

   • For adolescents: Extra caution is warranted as they may have lower seizure thresholds and more prolonged seizures with ECT than adults 1

Clinical Considerations and Caveats

• If medications cannot be discontinued due to clinical necessity, they may be administered with appropriate monitoring 1

• Patients with epilepsy on antiepileptic drugs may still receive ECT, though dose reductions may be required in some cases 6

• Prolonged seizures (>180 seconds) can occur in 0-10% of ECT treatments and may require termination with additional methohexital, diazepam, or lorazepam 1

• Tardive seizures (occurring hours after ECT) are a rare but serious side effect that requires neurological consultation 1

• For patients who develop prolonged seizures during ECT, consider neurological consultation and potential use of antiepileptic medications after completion of ECT course 1

Post-ECT Medication Considerations

• After completing the ECT course, medications can typically be restarted based on clinical need 1

• Careful monitoring should be provided for at least 24 hours after ECT for potential tardive seizures 1

• If seizure-related complications occur, appropriate medical consultation should be obtained before resuming ECT 1