What medications should be stopped before Electroconvulsive Therapy (ECT)?

Medications to Discontinue Before ECT

The following medications should be discontinued prior to ECT: lithium, benzodiazepines, carbamazepine, theophylline, and trazodone, as these pose the highest risk for serious complications including acute brain syndrome, seizure induction failure, and prolonged seizures. 1, 2

High-Priority Medications Requiring Discontinuation

Lithium

• Must be discontinued when clinically possible due to reports of acute brain syndrome and delirium when used concurrently with ECT 1, 3
• Lithium combined with ECT adds significant risk of organic syndromes developing 3

Anticonvulsants

• Carbamazepine should be stopped as it has been associated with failure to induce seizures during ECT and may prolong the action of succinylcholine 1, 3
• Valproate, lamotrigine, gabapentin, and topiramate may inhibit seizure activity and should be carefully considered for discontinuation 3, 4
• Recent evidence suggests anticonvulsants may be a relative rather than absolute contraindication, but require careful risk-benefit assessment 4

Benzodiazepines

• Should be discontinued as they increase seizure threshold through anticonvulsant properties, potentially making it difficult to induce therapeutic seizures 1, 2, 3
• Their anticonvulsant effects may interfere with the therapeutic efficacy of ECT 3

Other High-Risk Medications

• Theophylline must be stopped as it prolongs seizure duration at both therapeutic and toxic levels 1, 2
• Trazodone should be discontinued due to reported adverse effects, specifically prolonged seizures during ECT 1, 2

Medications That Can Be Continued

Antidepressants

• Tricyclic antidepressants (TCAs) can be safely continued and may actually enhance ECT efficacy 3, 5
• Nortriptyline specifically enhances ECT efficacy and reduces cognitive adverse effects compared to placebo 5
• SSRIs do not significantly affect seizure duration (31.4 seconds vs 33.2 seconds with TCAs) and can be continued 6
• Venlafaxine resulted in weaker improvement and tended to worsen cognitive adverse effects, requiring more caution 5

Antipsychotics and Other Medications

• Antipsychotics are well tolerated with ECT and may be beneficial 3
• Olanzapine and mirtazapine can be continued as part of maintenance treatment strategy 2

Critical Management Considerations

Timing and Monitoring

• Monitor patients for at least 24 hours after ECT for tardive seizures (late-onset seizures occurring after full recovery from anesthesia) 7, 1
• Prolonged seizures (>180 seconds) occur in 0-10% of treatments and require termination with additional methohexital, diazepam, or lorazepam 7, 1

When Discontinuation Is Not Possible

• If medications cannot be discontinued due to clinical necessity, they may be administered with appropriate monitoring 1
• Obtain neurology consultation if recurrent prolonged seizures or tardive seizures occur 7, 1

Common Pitfalls to Avoid

• Do not use MAOIs carelessly with ECT, especially older irreversible varieties and in patients recently started on MAOI therapy 3
• Avoid calcium channel antagonists or use with great care to prevent significant cardiovascular depression 3
• CNS stimulants may prolong seizures and produce dysrhythmias and elevated blood pressure 3

Post-ECT Medication Restart

• Medications can typically be restarted after completing the ECT course based on clinical need 1
• Pharmacotherapy and/or maintenance treatment should be initiated after the last ECT treatment, as ECT does not prevent future relapse 7