Medication Management During Active ECT Treatment
Continue most psychiatric medications during ECT, but discontinue specific high-risk agents (lithium, benzodiazepines, carbamazepine, theophylline, and trazodone) when clinically feasible, while actively adjusting antidepressants to enhance ECT efficacy. 1, 2, 3
Medications That Should Be Discontinued
High-priority discontinuations before and during ECT include:
- Lithium: Discontinue due to risk of acute brain syndrome and neurotoxicity when combined with ECT 1, 2
- Benzodiazepines: Taper off as they increase seizure threshold, potentially preventing adequate therapeutic seizures 1, 2
- Carbamazepine: Stop due to reports of failure to induce seizures during ECT 1, 2
- Theophylline: Discontinue as it prolongs seizure duration at both therapeutic and toxic levels 1, 2
- Trazodone: Avoid due to risk of prolonged seizures during ECT 1, 2
Medications to Continue and Actively Adjust
Antidepressants should be continued and optimized during ECT, as this approach substantially enhances treatment efficacy:
- Nortriptyline (or other TCAs) should be continued or initiated during ECT, as it enhances efficacy and actually reduces cognitive adverse effects compared to placebo 3
- Venlafaxine can be continued but produces weaker enhancement of ECT efficacy and may worsen cognitive side effects 3
- SSRIs and other antidepressants are generally safe to continue with appropriate monitoring 1, 4
Antipsychotics should be continued during ECT, as the combination is well-tolerated and may be beneficial 5, 6
Mood stabilizers like valproate can be continued with monitoring, though they may theoretically inhibit seizure activity 6, 7
Clinical Algorithm for Medication Adjustment
Step 1: Medication Review (Before ECT Course)
- Identify and discontinue high-risk medications (lithium, benzodiazepines, carbamazepine, theophylline, trazodone) when clinically possible 1, 2
- Ensure antidepressant is at therapeutic dose or consider adding nortriptyline to enhance ECT response 3
Step 2: During Active ECT Course
- Continue antidepressants and antipsychotics without interruption 5, 6, 3
- Monitor for adequate seizure induction at each session; if seizures are difficult to induce, reassess for anticonvulsant medications that may have been missed 1, 7
- Adjust antidepressant doses upward if partial response occurs, rather than waiting until after ECT completion 3
Step 3: If Medications Cannot Be Discontinued
- When clinical necessity requires continuing potentially problematic medications, administer with enhanced monitoring 1
- For patients on anticonvulsants for epilepsy, most can proceed with ECT without dose adjustment, though some may require reduction 8, 7
Important Caveats and Pitfalls
Common pitfall: Unnecessarily stopping all psychiatric medications before ECT based on outdated practice patterns from the 1960s-1970s. The evidence clearly shows that concomitant antidepressant treatment enhances ECT efficacy 3
Adolescent considerations: Exercise extra caution as adolescents may have lower seizure thresholds and more prolonged seizures than adults, requiring careful anesthetic dosing adjustments 1, 9
MAOIs require special attention: Older irreversible MAOIs combined with ECT add significant risk and require more careful management, particularly in recently initiated therapy 6
Monitoring priorities: Watch for prolonged seizures (>180 seconds), which occur in 0-10% of treatments and may require termination with additional methohexital, diazepam, or lorazepam 9