Background: Lithium is a helpful adjunct to patients undergoing ECT. However, only case reports and limited data suggest increase risk of delirium. Thus, this continues to be a controversial issue. Objective: In this study, we examine 1) The association and odds of delirium and cognitive problems with ECT and lithium (ECT þ Li) combination compared to ECT alone, 2) If positively associated, would this association vary by both type of mood episode and type of disorder? Methods: A national sample of 64,728 adult psychiatric inpatients across the US (identified from a total data of about 70 million total discharges annually) was analyzed using linear-by-linear association and logistic regression to assess the odds ratio (OR) for delirium and cognitive impairment for those treated with lithium (N ¼ 158), ECT (N ¼ 64148), or ECT þ Li (N ¼ 422) after adjusting for demographics and psychiatric diagnoses. Results: The prevalence of delirium was higher in the ECT þ Lithium group (5.7%) vs. ECT only (0.6%) or lithium only groups (0%). Patients managed with ECT þ Lithium have 11.7-fold higher odds (95% CI 7.55 e17.99, P < 0.001) of delirium compared to ECT alone. In the ECT þ Li group, delirium prevalence was 7.8% in unipolar depression, 3.4% in bipolar depressed, 0% in bipolar mania. Conclusion: These results are surprising given the fading concern about delirium association with ECT þ lithium combination. The high odds in the combination group warrant clinical caution, use of lower lithium doses (if combinations cannot be avoided), and vigilance regarding early signs of delirium. These results warrant replication in future studies.

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Objective: This study aims to systematically review the literature on using electroconvulsive therapy (ECT) in patients with dementia/major NCD (Neuro cognitive disorder) presenting with behavioral symptoms. Design: We conducted a PRISMA-guided systematic review of the literature. We searched five major databases, including PubMed, Medline, Embase, Cochrane, and registry (ClinicalTrials.gov), collaborating with “ECT” and “dementia/major NCD” as our search terms. Measurements: Out of 445 published papers and four clinical trials, only 43 papers and three clinical trials met the criteria. There were 22 case reports, 14 case series, 4 retrospective chart reviews, 1 retrospective case–control study, 1 randomized controlled trial, and 2 ongoing trials. We evaluated existing evidence for using ECT in dementia/major NCD patients with depressive symptoms, agitation and aggression, psychotic symptoms, catatonia, Lewy body dementia/major NCD, manic symptoms, and a combination of these symptoms. Settings: The studies were conducted in the in-patient setting. Participants: Seven hundred and ninety total patients over the age of 60 years were added. Results: All reviewed studies reported symptomatic benefits in treating behavioral symptoms in individuals with dementia/major NCD. While transient confusion, short-term memory loss, and cognitive impairment were common side effects, most studies found no serious side effects from ECT use. Conclusion: Current evidence from a systematic review of 46 studies indicates that ECT benefits specific individuals with dementia/major NCD and behavioral symptoms, but sometimes adverse events may limit its use in these vulnerable individuals.

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