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CTF Psychiatry Forum>
Lithium and ECT
Ricky
8 posts
Feb 23, 2011
10:00 PM
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Dear Dr. Sanil/psychiatrist,
Consider the following case:
A 68-year-old man is about to commence a course of electro-convulsive therapy for a
severe bipolar depression. His regular medication is sodium valproate 1000mgs daily,
lithium carbonate 750 mgs nocte, citalopram 40mgs daily, and small doses of
methotrimeprazine to help him sleep and to relieve daytime agitation.
Besides cessation of Valproate, would you consider stopping Lithium as well? As Lithium could increase risk of post-ECT delirium. On the contrary, ECT could induce mania which could be more significant than delirium.
Given that this man has SEVERE Bipolar history, I think I would continue with the Lithium.
What do u think?
Ricky
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Moderator
116 posts
Feb 24, 2011
4:38 AM
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Hi ,
Risk benefit analysis would be the best way to approach this. Stopping lithium for 24 to 48 hrs before ECT and then restarting after is another recommended way around this. Stopping lithium completely increases the risk of relapse significantly ( about 50% increased risk of relapse if lithium is stopped before 3-5 years. ).
The second issue in these cases especially since the client is 68 is an organic differential. Remember fronto temporal dementia can present with bipolar type picture and especially a resistant type of illness.( important is the onset of his illness late or early ) If he does have bipolar disorder then the absence of an antipsychotic is conspicious. Any reasons for this??
An antipsychotic can additionally be used to manage his agitation and his sleep in place of the sedative currently being used. The best evidence for bipolar disorder management , especially in acute phases includes an antipsychotic and mood stabilisers.
A physical examination for subcortical features is warranted and hopefully MRI / CT / EEG have been done at some point. I would suspect he has vascular factors playing a role as well ( hypertension and/or diabetes that may be contributing to the subcortical picture, is that the case??)
Hope this helps! interesting case. keep us posted
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Psychiatrist
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phil
4 posts
Jan 20, 2012
12:27 AM
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I seem to recall something about lithium prolonging the effect of musclerelaxants like suxamethonium or something. Anyone else heard of this?
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supernaut76
3 posts
Jan 20, 2012
10:40 PM
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Yeah but that seems like a minor problem - easily overcome in the ECT suite with prolonged monitoring in contrast to the the more serious problem of managing a manic relapse.
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