Lithium and ECT: Case Report from Germany

Out on PubMed, in JECT, is this report from researchers in Aachen, Germany:

Lithium Is Likely to Persist in the Brain: Clinical Implications for Electroconvulsive Therapy.

Augustin M, Karakavuz R, Riester L, Grözinger M.J ECT. 2021 Mar 1;37(1):67-70. doi: 10.1097/YCT.0000000000000719.PMID: 33600119

The abstract is copied below:

Electroconvulsive therapy and concomitant lithium therapy remain a matter of debate because of increased rates of adverse events. Current recommendations include monitoring lithium levels and reducing lithium to minimally effective dose. We present a report on protracted effects of lithium intoxication as electroconvulsive therapy 8 days after intoxication and under normal lithium serum levels resulted in a prolonged seizure. Electroencephalogram recordings before stimulation showed electroencephalogram correlates of subsiding lithium intoxication most likely due to protracted lithium influx and efflux of the central nervous system.

Part of the text is copied below:

This is a very complicated case of a 68-year old woman with a left ventricular assist device and on a long list of medications who had a prolonged seizure after an episode of lithium intoxication. I generally do not like to be a Monday morning quarterback...and I think we need to be very cautious in extrapolating from this rare and arcane circumstance to general practice.

Yes, too much residual lithium in the brain may have contributed to a prolonged seizure. I agree that too much lithium was the problem, and this patient should probably be on a lower dose, end of story. Since the lithium is being used as an augmenting strategy to an antidepressant, full "therapeutic" levels may not be necessary. Lithium gets a bad rap because practitioners often try to push the dose; adverse effects are the result. Some lithium is better than no lithium, and some lithium is better than too much lithium.

As to the ECT-lithium combination, caution is necessary and prudent, but the usual recommendation of holding a dose or two, to be sure levels are low, remains reasonable. The main message of this report, that extra time may be needed for lithium clearance from the brain after lithium toxicity, is also reasonable.

I applaud Dr. Augustin and colleagues for their sophisticated ECT care of this patient and agree with their assessment and recommendations; I just hope the title of the report is not misinterpreted as a call to further restrict the cautious concomitant use of ECT and lithium.