Psychiatric Pharmacy Essentials: Medications and Electroconvulsive Therapy (ECT)

Electroconvulsive therapy (ECT) is a psychiatric treatment for severe mental illness (emphasis on bipolar disorder, depression, suicidality, and catatonia) that involves passing small electric currents through the brain to induce a brief seizure or convulsion. This is often saved for patients who have not responded or have had insufficient response to medications.

  • Where does ECT play a role in the treatment of mental illness?1-7
  • What do current psychiatric guidelines recommend?8-9
  • What is the recommended frequency and duration of ECT?10
  • What recommendations are available for ECT use in pregnancy?11-12
  • What role does anesthesia play in ECT?13-15
  • How should anesthetics be chosen?16
  • What are significant drug-drug interactions with ECT and how should they be managed?17-20
  • How do psychotropic medications effect seizure threshold and how will it affect ECT?21-22
  • What are suggested augmentation strategies with ECT?23-25
  • What evidence is there for efficacy and safety of using ECT in depressed older adults?26-28
  • What is the long-term safety of maintenance ECT?29
  • What are recommended textbooks that may serve as good references regarding ECT?30-33

Reviewer 1: Trisha McHugh, PharmD
Reviewer 2: Austin Smith, PharmD, BCPP
2024-2025 AAPP Resident and New Practitioner Committee

References

  1. Lisanby SH. Electroconvulsive therapy for depression. N Engl J Med. 2007;357(19):1939-45. DOI: 10.1056/NEJMct075234. PubMed PMID: 17989386.
  2. Goodman WK. Electroconvulsive therapy in the spotlight. N Engl J Med. 2011;364(19):1785-7. DOI: 10.1056/NEJMp1101096. PubMed PMID: 21561344.
  3. Zolezzi, M. Medication management during electroconvulsant therapy. Neuropsychiatr Dis Treat. 2016;12:931-9. [PubMed]
  4. Tess AV, Smetana GW. Medical evaluation of patients undergoing electroconvulsive therapy. N Engl J Med. 2009;360(14):1437-44. DOI: 10.1056/NEJMra0707755. PubMed PMID: 19339723.
  5. Li M, Yao X, Sun L, et al. Effects of Electroconvulsive therapy on depression and its potential mechanism. Front Psychol. 2020;11:80. [PubMed]
  6. Elias A, Thomas N, Sackeim HA. Electroconvulsive therapy in mania: a review of 80 years of clinical experience. Am J Psychiatry. 2021;178(3):229-239. [PubMed]
  7. Lloyd JR, Silverman ER, Kugler JL, Cooper JJ. Electroconvulsive therapy for patients with catatonia: current perspectives. Neuropsychiatr Dis Treat. 2020;16:2191-2208. [PubMed]
  8. American Psychiatric Association committee on electroconvulsive therapy. The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging. 2nd ed. Washington, DC: American Psychiatric Association; 2001. [Weblink] (Link to Book Only)
  9. Weiss A, Hussain S, Ng B, et al. Royal Australian and New Zealand College of Psychiatrists professional practice guidelines for the administration of electroconvulsive therapy. Aust N Z J Psychiatry. 2019;53(7):609-623. [PubMed]
  10. Gangadhar BN, Thirthalli J. Frequency of electroconvulsive therapy sessions in a course. J ECT. 2010;26(3):181-185. [PubMed]
  11. Ward HB, Fromson JA, Cooper JJ, De Oliveira G, Almeida M. Recommendations for the use of ECT in pregnancy: literature review and proposed clinical protocol. Arch Womens Ment Health. 2018;21(6):715-722. [PubMed]
  12. Rose S, Dotters-Katz S, Kuller J. Electroconvulsive therapy in pregnancy: safety, best practices, and barriers to care. Obstet Gynecol Surv. 2020;75(3):199-203. [PubMed]
  13. Ding Z and White PF. Anesthesia for electroconvulsive therapy. Anesth Analg. 2002; 94(5):1351-64. [PubMed]
  14. Folk JW, Kellner CH, Beale MD, Conroy JM, Duc TA. Anesthesia for electroconvulsive therapy: a review. J Ect. 2000;16(2):157-70. DOI: 10.1097/00124509-200006000-00007. PubMed PMID: 10868325.
  15. Soehle M, Bochem J, Kayser S, Weyerhäuser J, Valero R. Challenges and pitfalls in anesthesia for electroconvulsive therapy. Best Pract Res Clin Anaesthesiol. 2021;35(2):181-189. [PubMed]
  16. Wagner KJ, Möllenberg O, Rentrop M, Werner C, Kochs EF. Guide to anaesthetic selection for electroconvulsive therapy. CNS Drugs. 2005;19(9):745-58. DOI: 10.2165/00023210-200519090-00002. PubMed PMID: 16142990.
  17. Mehta V, Mueller PS, Gonzalez-Arriaza HL, Pankratz VS, Rummans TA. Safety of electroconvulsive therapy in patients receiving long-term warfarin therapy. Mayo Clin Proc. 2004;79(11):1396-401. DOI: 10.4065/79.11.1396. PubMed PMID: 15544018.
  18. Naguib M, Koorn R. Interactions between psychotropics, anaesthetics and electroconvulsive therapy: implications for drug choice and patient management. CNS Drugs. 2002;16(4):229-47. DOI: 10.2165/00023210-200216040-00003. PubMed PMID: 11945107.
  19. Patel RS, Bachu A, Youssef NA. 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. Brain Stimul. 2020;13(1):14-19. [PubMed]
  20. Zolezzi, M. Medication management during electroconvulsant therapy. Neuropsychiatr Dis Treat. 2016;12:931-9. [PubMed]
  21. Pisani F, Oteri G, Costa C, Di Raimondo G, Di Perri R. Effects of Psychotropic Drugs on Seizure Threshold. Drug Saf. 2002;25(2):91- 110. DOI: 10.2165/00002018-200225020-00004.
  22. Tang VM, Pasricha AN, Blumberger DM, et al. Should benzodiazepines and anticonvulsants be used during electroconvulsive therapy?: A case study and literature review. J ECT. 2017;33(4):237-42. [PubMed]
  23. Loo C, Simpson B, MacPherson R. Augmentation strategies in electroconvulsive therapy. J ECT. 2010; 26(3):202-7. [PubMed]
  24. Datto C, Rai AK, Ilivicky HJ, et al. Augmentation of seizure induction in electroconvulsive therapy: a clinical reappraisal. J ECT. 2002; 18(3):118-25. [PubMed]
  25. Anderson IM, Blamire A, Branton T, et al. Ketamine augmentation of electroconvulsive therapy to improve neuropsychological and clinical outcomes in depression (Ketamine-ECT): a multicentre, double-blind, randomised, parallel-group, superiority trial. Lancet Psychiatry. 2017;4(5):365-377. [PubMed]
  26. Kellner CH, Husain MM, Knapp RG, et al. Right unilateral ultrabrief pulse ECT in geriatric depression: phase 1 of the PRIDE study. Am J Psychiatry. 2016;173(11):1101-1109. [PubMed]
  27. Lisanby SH, McClintock SM, Alexopoulos G, et al. Neurocognitive effects of combined electroconvulsive therapy (ECT) and venlafaxine in geriatric depression: phase 1 of the PRIDE study. Am J Geriatr Psychiatry. 2020;28(3):304-316. [PubMed]
  28. Lisanby SH, McClintock SM, McCall WV et al. Longitudinal neurocognitive effects of combined electroconvulsive therapy (ECT) and pharmacotherapy in major depressive disorder in older adults: phase 2 of the PRIDE study. Am J Geriatr Psychiatry. 2022;30(1):15-28. [PubMed]
  29. Luccarelli J, McCoy TH Jr, Seiner SJ, Henry ME. Maintenance ECT is associated with sustained improvement in depression symptoms without adverse cognitive effects in a retrospective cohort of 100 patients each receiving 50 or more ECT treatments. J Affect Disord. 2020;271:109-114. [PubMed]
  30. Mankad MV and Weiner RD (2010). Anesthetics and Other Medications. In Mankad MV, Beyer JL, Weiner JL, Krystal AD. Clinical Manual of Electroconvulsive Therapy (pp. 81-93).ISBN: 1585622699, 978-1585622696 [Amazon Smile]
  31. Anesthesia Management for Electroconvulsive Therapy: Practical Techniques and Physiological Background 1st ed. 2016 Edition. [Amazon Smile]
  32. Handbook of ECT: A Guide to Electroconvulsive Therapy for Practitioners 1st Edition by Charles H. Kellner. [Amazon Smile]
  33. The Practice Of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging 2nd Edition by American Psychiatric Association. [Amazon Smile]