Low Levels of Lithium and ECT: Small Study From Portugal

 Out on PubMed, from investigators in Portugal, is this study:

Absence of Longer Reorientation Times in Patients Undergoing Electroconvulsive Therapy and Concomitant Treatment with Lithium.

Martins-Ascencao R, Rodrigues-Silva N, Trovão N.Clin Psychopharmacol Neurosci. 2021 Nov 30;19(4):695-704. doi: 10.9758/cpn.2021.19.4.695.PMID: 34690124
The abstract is copied below:

Objective: Lithium is a drug of choice in the treatment of bipolar disorder and refractory depressive disorders. However, previous research suggests lithium has a negative cognitive impact in recovery from electroconvulsive therapy (ECT) and a higher risk of delirium, so patients are often required to stop taking lithium before ECT, despite risk of relapse. We studied the cognitive impact of serum lithium levels in patients undergoing ECT.

Methods: This was an observational prospective study. Serum lithium levels, thyroid and biochemical parameters were measured prior to each ECT session. Time elapsed from the anesthetic induction to the electrical stimulus and then to the patients' reorientation was recorded, as well as the motor seizure duration and electroencephalogram (EEG) seizure duration. A statistical analysis using a linear mixed model was run while adjusting for confounding factors.

Results: Ten participants underwent a total of 86 ECT sessions (41% right unilateral ultrabrief pulse, and 59% bilateral brief pulse). A negative interaction between lithium levels and reorientation time was found among those doing bilateral brief pulse ECT. No association was observed in patients doing unilateral ultrabrief pulse ECT. No significant relationship was observed between lithium and both motor and EEG-assessed seizure duration.

Conclusion: This study suggests that low to moderate serum lithium levels (< 0.7 mmol/L) might have no harmful cognitive effects in patients under right unilateral ultrabrief pulse and bilateral brief pulse ECT.

Keywords: Cognitive dysfunction; Confusion; Electroconvulsive therapy; Lithium; Orientation.

The pdf is here.


This is an interesting study with counterintuitive results and a very thoughtful discussion including frank admission of limitations. Yes, higher lithium levels (all within a low range) were associated with SHORTER recovery times with BL electrode placement; no association was seen with RUL. At the very least, these data contribute a bit to the evidence base of the safety/tolerability of concomitant lithium and ECT. The authors raise the possibility that low levels of lithium might even be neuroprotective-a bit of a stretch, but theoretically interesting. The data on the much longer recovery time with thiopental vs propofol is also interesting.
So, no reason to change the typical, moderately conservative practice of holding the prior night's lithium dose before ECT.
Practitioners will find this a useful paper, a full read will be ~ 15 minutes.

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