Combination of lithium and electroconvulsive therapy (ECT) is associated with higher odds of delirium and cognitive problems in a large national sample across the United States

Abstract

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.

Does lithium prevent relapse following successful electroconvulsive therapy for major depression? A systematic review and meta‐analysis

“…Moreover, it has been suggested to use a low dose of lithium and hold it for at least 24 hours before each ECT session. 45 Although our meta-analysis supports the use of lithium in the prevention of relapse following successful ECT for major depression, and positive effects on relapse rates are equally seen with lithium in combination with C-ECT, it seems that only a minority of patients in clinical practice Numbers, proportions, and means of the sample extracted from additional data were used. Therefore, values in the table may not match the values in the original papers.…”

Relapse following bitemporal and high‐dose right unilateral electroconvulsive therapy for major depression

“…However, in that study, unlike in ours, lithium was added to antidepressants after completion of the ECT course. However, caution regarding dosing is warranted when administering lithium concurrently with ECT due to increased risk of delirium 27 …”

Patient-level Characteristics and Inequitable Access to Inpatient Electroconvulsive Therapy for Depression: A Population-based Cross-sectional Study: Caractéristiques au niveau du patient et accès inéquitable à la thérapie électroconvulsive pour patients hospitalisés

“…24 One potential explanation is that individuals with bipolar depression are often treated with mood stabilizers, such as lithium or anticonvulsants, 25 which may interfere with the efficacy of ECT or increase risk of complications. 26,27 While there are no absolute contraindications to ECT, medical comorbidities or active substance use may increase the safety risk of providing treatment with ECT, likely due to risks associated with general anesthesia, and reduced odds of use in the presence of these characteristics reflect appropriate practice patterns. 7,28…”