Electroconvulsive therapy with lithium

Combining lithium with typical antipsychotics may cause neurotoxicity (e.g., delirium, cerebellar dysfunction, extrapyramidal symptoms). Lithium should be withdrawn and discontinued at least 2 days before electroconvulsive therapy. 

Ensuring that other drugs or treatments are not administered which may interact with the psychotropic drug under investigation (e.g. lithium, electroconvulsive therapy). 

Small IF, Milstein V, Miller MJ, et al Electroconvulsive treatment—indications, benefits, and limitations. Am J Psychother 40 343-356, 1986 Small JG, Klapper MH, Kellams JJ, et al Electroconvulsive therapy compared with lithium in the management of manic states. Arch Gen Psychiatry 45 727-732, 1988... 

Lithium has been proven effective for acute and prophylactic treatment of both manic and depressive episodes in patients with bipolar illness (American Psychiatric Association 2002). However, patients with rapid-cycling bipolar disorder (i.e., patients who experience four or more mood disorder episodes per year) have been reported to respond less well to lithium treatment (Dunner and Fieve 1974 Prien et al. 1984 Wehr et al. 1988). Lithium is also effective in preventing future depressive episodes in patients with recurrent unipolar depressive disorder (American Psychiatric Association 2002) and as an adjunct to antidepressant therapy in depressed patients whose illness is partially refractory to treatment with antidepressants alone (discussed in Chapter 2). Furthermore, hthium may be useful in maintaining remission of depressive disorders after electroconvulsive therapy (Coppen et al. 1981 Sackeim et al. 2001). Lithium also has been used effectively in some cases of aggression and behavioral dyscontrol. 

It is well established that monotherapy with various antidepressants or mood stabilizers is relatively ineffective (i.e., they are necessary but not sufficient) for treating mood disorders with associated psychosis. Thus, psychotically depressed patients are best managed with a combination of antipsychotic-antidepressant or with electroconvulsive therapy. Although antipsychotics have a more rapid onset of action than lithium in an acute manic episode, we are unaware of clinical trials that examine the differential effect of antipsychotics or lithium for nonpsychotic versus psychotic mania. This topic is discussed further in... 

Hoenig, J., Chaulk, R. (1977). Delirium associated with lithium therapy and electroconvulsive therapy. Canadian Medical Association Journal, 116, 837-838. 

The adverse effects of lithium in elderly patients include cognitive status worsening, tremor, and hypothyroidism. The authors suggested that divalproex is also useful in elderly patients with mania and that concentrations of divalproex in the elderly are similar to those useful for the treatment of mania in younger patients. They noted that carbamazepine should be considered a second-line treatment for mania in the elderly. A partial response would warrant the addition of an atypical antipsychotic drug. For bipolar depression, they recommended lithium in combination with an antidepressant, such as an SSRI. They also noted that lamotrigine may be useful for bipolar depression. Electroconvulsive therapy (ECT) may also be useful, but there have been no comparisons of ECT and pharmacotherapy in elderly patients with bipolar depression. 

More recently, newer medicines have been used to treat bipolar manic depression disorder. Carbamazepine and valproate are two anticonvulsants that have been particularly useful with patients who do not respond to lithium. These medications also have to be monitored for proper dosages. Antidepressants may be necessary during severe depressive episodes but may push a patient into the manic state. In severe cases, hospitalization and even electroconvulsive therapy (ECT) may be necessary. 

Psychopharmacological agents such as antidepressants, antipsychotics (in patients with personality disorders) and lithium (in patients with bipolar disorders) have been shown to be effective in preventing suicidal behavior. The efficacy of electroconvulsive therapy (ECT) is more controversial. Another equally important aspect of the optimal clinical management of suicidal patients is the quality of the doctor-patient relationship. 

Augmentation is called for when there is partial or non-response to the above approaches. Combinations of SSRIs with buspirone, clonazepam, clonidine, inositol, lithium, pindolol, olanzapine, risperidone, trazodone, tryptophan, and venlafaxine have been reported, with limited benefit. To date, only two augmenting agents have been found to be effective in double-blind studies risperidone and pindolol. Augmentation of SSRIs with clomipramine (or vice versa) is a common practice in non-responders however, this combination may lead to a substantial increase in the level of tricyclics in the blood and/or increase the risk of serotonin syndrome. Phenelzine may be helpful in symmetry-related or other atypical obsessions. Electroconvulsive therapy (ECT) should be reserved for severely depressed and suicidal OCD patients. Neurosurgery is the last resort current operations include anterior cingulotomy, anterior capsulotomy, subcaudate tractotomy, and limbic leucotomy. The outcome of such operations is questionable. 

In resistant patients, the combination of SCAs and lithium or carbamazepine seems a reasonable approach. Carbamazepine is contraindicated as augmentation therapy to clozapine, due to their synergistic effects on bone marrow suppression. Electroconvulsive therapy (ECT) may also be considered for patients with severe or treatment-resistant... 

Severe lithium toxicity is associated with seizures. In two cases, seizures were associated with high lithium concentrations (4.86 mmol/1 in a 25-year-old woman and 2.5 mmol/1 in a 48-year-old man) [44 ]. A third case occurred in a 20-year-old man whose lithium concentration was only 0.8 mmol/1 [45 ]. Status epUepticus that lasted 45 minutes occurred in a middle-aged woman undergoing electroconvulsive therapy (ECT) while she had therapeutic serum concentrations of lithium and was also taking agents that reduce the seizure threshold (clomipramine and quetiapine) [46 ]. It has been previously proposed that ECT can cause the intracellular concentration of lithium to rise without a concomitant rise in serum concentration [47 ]. 

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