REVIEW

Should Benzodiazepines and Anticonvulsants Be Used During

Electroconvulsive Therapy?
A Case Study and Literature Review
Victor M. Tang, MD, MSc,*† Akash N. Pasricha, BSc,† Daniel M. Blumberger, MD, MSc, FRCPC,*†‡§
Daphne Voineskos, MD, FRCPC,*† Suvercha Pasricha, MBBS, FRCPC,||¶
Benoit H. Mulsant, MD, MS, FRCPC,*†‡§ and Zafiris J. Daskalakis, MD, PhD, FRCPC*†‡§

benzodiazepines and anticonvulsants impact the clinical outcomes of

Objective: This study aims to investigate the clinical effects of benzo- ECT less than what would be expected given their pharmacologic effects.
diazepines or anticonvulsant use during a course of electroconvulsive However, there are significant gaps in the literature, including a lack of
therapy (ECT). study on suprathreshold stimulation of right unilateral ECT and the possi-
Method: A case report study of a patient who received ECT with and bility of a greater effect with higher medication doses.
without concomitant flurazepam and pregabalin is presented. The literature
on the use of benzodiazepines and anticonvulsants during ECT is reviewed. Key Words: electroconvulsive therapy, benzodiazepines,
Results: A woman with treatment resistant depression received a course anticonvulsant mood stabilizers, seizure duration, seizure threshold
of ECT while taking flurazepam and pregabalin, but seizures were of short (J ECT 2017;00: 00–00)
duration and symptomatic improvement was minimal. After discontinua-
tion of flurazepam and pregabalin, a course of right unilateral ultrabrief
ECT was associated with adequate seizures and remission of depression
and suicidal ideation. Our literature review suggests that benzodiazepines
E lectroconvulsive therapy (ECT) is considered as one of the
most effective treatments for mental illnesses, particularly ma-
jor depressive disorder (MDD). Review of existing pharmacother-
decrease seizure duration, but most evidence shows no association with in- apy before and during a course of ECT is of clinical importance as
creased seizure threshold. One prospective RCT and 3 large retrospective many medications can affect the efficacy of ECT.1 In this article,
studies found that benzodiazepines compromise the efficacy of unilateral we describe the case of a patient with MDD who was treated with
but not bilateral ECT. Regarding anticonvulsants, several studies had varied 2 courses of ECT, before and after discontinuation of her benzodi-
and contradictory results on their effect on seizure duration and seizure azepine and anticonvulsant mood stabilizer. In this context, we re-
threshold. Of the 2 large retrospective studies and 3 RCTs, only 1 retro- view the literature on the physiological effects of benzodiazepines
spective study showed that anticonvulsants decrease the efficacy of ECT. and anticonvulsants on seizures during ECT and the efficacy of
Conclusions: Judicious assessment of all medications used in combina- ECT when delivered concomitantly with these medications. The
tion with ECT is recommended. Overall, published studies suggest that patient described in this article provided written consent to have
her case reported.
From the *Department of Psychiatry, †Temerty Centre for Therapeutic Brain
Intervention, Centre for Addiction and Mental Health, ‡Campbell Family
Mental Health Research Institute, Centre for Addiction and Mental Health,
CASE REPORT
§Institute of Medical Science, Faculty of Medicine, ||Women's Inpatient Unit, Mrs A was a 59-year-old divorced mother of 2 children ad-
Centre for Addiction and Mental Health, and ¶Department of Psychiatry, University mitted to a community hospital for MDD, opioid abuse, and bor-
of Toronto, Toronto, Ontario, Canada.
Received for publication April 30, 2017; accepted June 16, 2017.
derline personality traits. Her past psychiatric history was
Reprints: Zafiris J. Daskalakis, MD, PhD, FRCPC, Centre for Addiction and significant for several hospitalizations owing to suicide attempts,
Mental Health, 1001 Queen St W, Unit 4-1, Toronto, Ontario, M6J1H4, childhood trauma including sexual abuse, postpartum depression,
Canada (e‐mail: Jeff.Daskalakis@camh.ca). and previous cocaine abuse. Her medications at that time included
D.M.B. receives research support from the Canadian Institutes of Health
Research (CIHR), Brain Canada, Weston Brain Institute, National Institutes
bupropion, asenapine, desvenlafaxine, flurazepam, clonazepam,
of Health (NIH), Temerty Family through the Centre for Addiction and propranolol, quetiapine, pregabalin, and gravol. Initially, she
Mental Health (CAMH) Foundation, and the Campbell Family Research was treated with 8 sessions of ECT, 2 of which used right uni-
Institute. He received nonsalary operating funds and in-kind equipment lateral (RUL) electrode placement and 6 using bilateral (BL)
support from Brainsway Ltd for an investigator-initiated study. He is the
site-principal investigator for 3 sponsor-initiated clinical trials from
electrode placement (Table 1). During this first ECT course,
Brainsway Ltd. He received in-kind equipment support from Tonika/ Mrs A was receiving her benzodiazepines (flurazepam 30 mg/day
Magventure for an investigator-initiated study. He received medication and clonazepam 1 mg 4 times a day) and an anticonvulsant
supplies from Indivior for an investigator-initiated trial. In the last 5 years, (pregabalin 75 mg, 4 times a day). Evidence of motor seizure in a
B.H.M. has received research support from Brain Canada, the CAMH
Foundation, the CIHR, the NIH, Bristol-Myers Squibb (medications for an
cuffed limb lasted 5 to 20 seconds, and her electroencephalographic
NIH-funded clinical trial), Eli Lilly (medications for an NIH-funded clinical (EEG) seizure duration lasted 7 to 26 seconds during this first
trial), and Pfizer (medications for an NIH-funded clinical trial). In the last course of ECT. There was no change in her mood, suicidality, or
3 years, Z.J.D. has received research and equipment in-kind support for an overall clinical picture with ECT.
investigator-initiated study through Brainsway Inc and Magventure Inc.
Z.J.D. has also received monies for participation on an advisory board from
Mrs A was then referred to our academic psychiatric hospital
Sunovion Inc. Finally, Z.J.D. owns more than US $10,000 (CAD) in stock for a consultation for treatment-resistant depression. It was
of Biogen Inc. This work was supported by the Ontario Mental Health recommended that ECT be repeated after tapering off her
Foundation, the CIHR, the Brain and Behaviour Research Foundation, and flurazepam, clonazepam, and pregabalin. After she was admit-
the Temerty Family and Grant Family and through the CAMH Foundation
and the Campbell Institute. For the remaining authors, none were declared.
ted, her flurazepam was switched to diazepam and both diaze-
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. pam and clonazepam were then tapered off. Her pregabalin
DOI: 10.1097/YCT.0000000000000441 75 mg 4 times a day was reduced to only once daily. She remained

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Tang et al Journal of ECT • Volume 00, Number 00, Month 2017

mechanism, anticonvulsants mechanism, benzodiazepines with

TABLE 1. Electrode Placement and Seizure Duration During ECT, anticonvulsants with ECT, followed by a second PubMed
First Course of ECT
search with the following keywords: seizure duration with benzo-
diazepines, and seizure threshold with benzodiazepines.
Treatment No. 1 2 3 4 5 6 7 8
Stimuli Electrode placement RUL BL BL RUL BL BL BL BL
Duration, s M 6 6 11 20 6 6 5 9 Benzodiazepines
E – 9 11 26 12 8 7 18
Benzodiazepines primarily act on γ-aminobutyric acid
M indicates motor seizure; E, EEG seizure; −, data not collected. (GABA)A receptors2 by allosterically modulating the binding
of GABA to the receptor. For instance, diazepam increases
the frequency of chloride channel opening events on the GABA
extremely depressed and suicidal. Mrs A was then treated with 10 receptor, suppressing neuronal electrical activity in the brain.3
RUL ECT treatments using a stimulus intensity (ie, charge) 6-fold GABA inhibition has been found to play an important role in
higher than her seizure threshold as determined using a standard stopping a single epileptic seizure from developing into status
titration procedure. She reported an elevation in her mood after epilepticus.4 α-1 Subunits of GABAA receptors have been shown
the fifth treatment. In addition, while Mrs A was hospitalized to be involved in the anticonvulsant effects of diazepam5 and site-
and received her second ECT course, she was maintained on specific gene deletion of these α-1 subunits interferes with the an-
the same medications as admission except for a switch from ticonvulsive effects of diazepam.6
desvenlafaxine to duloxetine and initiation of trazodone for sleep. In addition to requiring a generalized seizure for effective
She also received trauma informed care based on dialectic behav- ECT treatment, the duration and quality of the seizure play an im-
ioral therapy principles. She was discharged from inpatient care portant role. Early reports have shown an association between ef-
after her 10th treatment. After discharge, she received continu- ficacy of ECT and seizure duration.7–9 For instance, the response
ation ECT weekly for 3 weeks, every 2 weeks for 1 month, and rate increases markedly when the cumulative seizure duration dur-
monthly for an additional 3 treatments (for a total of 8 continuation ing a course ECT increases: 2.7% response rate after 210 seconds
treatments). Tables 2 and 3 present both motor and EEG seizure du- of cumulative seizure duration; 79.5% after 750 seconds; and
rations during this second ECT course after discontinuation of her 92.4% after 1000 seconds.10 There is evidence that benzodiaze-
benzodiazepines and anticonvulsant. pines shorten seizure duration during ECT. For instance, an early
One year and 5 months after being discharged, and 1 year af- study of 23 patients receiving benzodiazepines and 20 patients
ter completion of ECT, Mrs A was no longer suicidal and reports a without benzodiazepines found that the average seizure duration
more positive outlook on her life. Although she still becomes decreased from 40.5 seconds to 34.4 seconds.11 Similarly, mean
slightly anxious in public settings, she describes herself as the seizure duration was reported to decrease from 32.6 to 24.0 sec-
most confident she has felt in her 59 years. Despite a prior history onds after administering 10 mg of diazepam for 12 hours.12 Thus,
of over 10 hospitalizations and over 10 suicide attempts (including concomitant use of benzodiazepines and ECT has been discour-
intensive care unit admissions), she has remained out of hospital aged for more than 30 years.13 Because of their anticonvulsant ef-
for her psychiatric illness since. Her maintenance medications in- fect, benzodiazepines have also been assumed to increase seizure
cluded bupropion, duloxetine, lurasidone, trazodone, propranolol, threshold.13,14 However, in a secondary analysis of data from a
pregabalin 75 mg once daily, and a much smaller dose of clonaz- multisite prospective study, Boylan et al15 found that benzodiaze-
epam 0.5 mg twice daily. pines shortened seizure duration but did not affect seizure thresh-
This case prompted us to review the literature and examine old. This result is congruent with the results of several other
the effects of benozodiazepines and anticonvulsant mood stabi- studies that have not found benzodiazepines to have an effect on
lizers) on the efficacy of ECT. seizure threshold.16–19 In contrast, in one study of 54 Japanese pa-
tients with various diagnoses, benzodiazepines were associated
with higher seizure threshold20; the authors commented that their
LITERATURE REVIEW patients received higher doses of benzodiazepines than the partic-
ipants in the study of Boylan et al.15 Galvez et al21 analyzed the
Method role of concomitant medications in 3 clinical trials of ECT in-
A first PubMed search with the following keywords was con- cluding 179 patients; they found no correlation between sei-
ducted: ECT, treatment resistant depression, benzodiazepines zure threshold and benzodiazepines. However, a systematic

TABLE 2. Parameters and Seizure Duration During Second Course of ECT (Acute)

Treatment No. 1 2 3 4 5 6 7 8 9 10
Stimulus (current 0.8 A) Width, ms 0.30 0.30 0.30 0.30 0.30 0.30 0.30 0.30 0.30 0.30
Frequency, Hz 20 80 80 80 80 80 80 80 80 80
Duration, s 4.00 6.00 6.00 6.00 6.00 6.00 6.00 6.00 6.00 6.00
Electrode placement RUL RUL RUL RUL RUL RUL RUL RUL RUL RUL
Charge, μ 38.4 230.4 230.4 230.4 230.4 230.4 230.4 230.4 230.4 230.4
Seizure Overall GM2+ GM 2+ GM 2+ GM 1+ GM 2+ GM 1+ GM 2+ GM 2+ GM 2+ GM 1+
Duration, s M 39 40 30 18 31 21 15 26 19 32
E 58 50 36 28 42 84 34 40 57 45
M indicates motor seizure; E, EEG seizure; GM, grand mal.

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Journal of ECT • Volume 00, Number 00, Month 2017 Benzodiazepines and Anticonvulsants During ECT

TABLE 3. Parameters and Seizure Duration During Continuation ECT

Treatment No. 1 2 3 4 5 6 7 8
Stimulus (current 0.8 A) Width, ms 0.30 0.30 0.30 0.30 0.30 0.30 0.30 0.30
Frequency, Hz 80 80 80 80 80 80 80 80
Duration, s 6.00 6.00 6.00 6.00 6.00 6.00 6.00 6.00
Electrode placement RUL RUL RUL RUL RUL RUL RUL RUL
Charge, μ 230.4 230.4 230.4 230.4 230.4 230.4 230.4 230.4
Seizure Overall GM 2+ GM 2+ GM 2+ GM 1+ GM 2+ GM 1+ GM 2+ GM 2+
Duration, s M 29 6 12 35 29 35 20 25
E 29 10 13 35 29 53 25 30
M indicates motor seizure; E, EEG seizure; GM, grand mal.

prospective examination of benzodiazepine dosage and seizure treated with ECT (typically, 12 sessions of BL ECT).27 There
threshold has not yet been done. was no significant association between benzodiazepine use and
Because the relationship among stimulus intensity, seizure treatment response. The authors suggest that this may be owing
threshold, and efficacy is different for RUL and BL ECT, some to almost all patients on benzodiazepines using less than 6 mg/day
studies have tried to distinguish between the effects of benzodiaz- of lorazepam equivalents, and that benzodiazepines were com-
epines on RUL ECT versus BL ECT. A stimulus intensity margin- monly held the evening before treatment by the treating physician.
ally higher than seizure threshold has minimal therapeutic effect
with RUL ECT but is effective with BL ECT.22 For instance, in Anticonvulsants
a randomized trial, RUL ECT at 8 times seizure threshold and
BL ECT at 1.5 times seizure threshold yielded similar response Mechanism of Action of Anticonvulsants
rates.23 Thus, benzodiazepines may impact RUL ECT and BL The anticonvulsants most likely to be used as mood stabi-
ECT differently.22 lizers are valproate, carbamazepine, and lamotrigine. Whereas
many cellular and molecular effects have been reported for these
medications, as all other effective antiepileptic medications, these
Efficacy of ECT when Delivered with Benzodiazepines 3 medications inhibit Na+ currents by binding to sodium chan-
Considering the wide array of research exploring anticonvul- nels.28 Like benzodiazepines, some anticonvulsants also interact
sant effects of benzodiazepines and seizure quality, the efficacy of with the GABA system. For instance, valproate increases cerebral
ECT in conjunction with these drugs has been questioned. The GABA concentrations,29 and carbamazepine potentiates GABA-
American Psychiatric Association recommends tapering benzodi- induced current via GABAA receptors.30
azepine dosage before the start of ECT.8 One study supports these Pregabalin and gabapentin reduce cellular concentrations of
guidelines: 93% of those who did not receive benzodiazepines glutamate, noradrenaline, acetylcholine, and substance P.31,32
during a RUL ECT trial responded to treatment in contrast versus These medications are not used as mood stabilizers but are anti-
only 62% of those using benzodiazepines.14 Moreover, when 11 convulsants that can be used in the treatment of epilepsy or
of the 14 nonresponders were subsequently switched to BL chronic pain. Pregabalin and gabapentin also act on α-2-δ pro-
ECT, 9 (82%) responded. In this study, the stimulus intensity teins, subunits of voltage-gated calcium channels.32 Reports have
was preselected and fixed based on age. Similarly, the efficacy demonstrated reduced calcium influx via these voltage-gated cal-
of ECT was compared retrospectively in 124 patients (85% with cium channels in nerve terminals, suggesting a mechanism for the
MDD; 15% with bipolar disorder) receiving benzodiazepines anticonvulsant effects of the 2 medications.33–35
and 124 patients who were not receiving benzodiazepine.24 Sei- By design, anticonvulsants prevent seizures. Despite this,
zure duration and titration methods were not accounted for, be- studies of patients undergoing ECT while taking anticonvulsants
cause these parameters were not recorded before 1995. Good have not shown that they have a clear effect on seizure parameters.
response to ECTwas reported in 12 (67%) of 18 patients receiving In one small retrospective chart review study, use of anticonvul-
UL ECT with benzodiazepine; 12 (86%) of 14 patients receiving sants during ECT was associated with shorter seizure durations
UL ECT without benzodiazepines; 92 (88%) of 106 patients re- with RUL ECT but not with BL ECT.36 Two small, retrospective
ceiving BL ECT with benzodiazepines; and 100 (91%) of case reviews of lamotrigine use during ECT found no significant
110 patients (91%) receiving BL ECT without benzodiazepines. clinical effect on seizure duration.37,38 For seizure threshold, 2
These studies suggest that the efficacy of RUL ECT is compro- prospective studies of BL ECT at 1.5 times seizure threshold
mised when delivered with benzodiazepines, whereas benzodiaz- did not find an association between anticonvulsant use and seizure
epines do not have the same effect on BL ECT. However, a study threshold.18,20 However, a larger analysis of 3 RCTs combined
explicitly designed to compare the impact of benzodiazepines on did find that they increased seizure threshold.25 Nonetheless, the
the efficacy of RUL and BL is needed to confirm these findings.14 association was only a weak correlation and was not significant
This conclusion is supported by a more recent retrospective in a multiple regression analysis. A recent retrospective chart
study in which 89 (99%) of 90 patients with MDD who were review of 650 patients receiving BL ECT found that a greater
treated with BL ECT and received benzodiazepines showed sig- proportion of those using anticonvulsants had high seizure
nificant improvement and 81 (90%) experienced a remission.25 thresholds defined as seizure with a charge greater than 120 mC.19
Stimulation dose levels were initially selected based on age26 It also found that age correlated with increased seizure thresh-
and titrated to ensure greater than or equal to 15 seconds of spike old, and a substantial portion (14.7%) of younger patients
and wave activity. Most recently, a large retrospective chart review (<40) had low seizure thresholds even though they were
was conducted in a cohort of 144 patients with schizophrenia receiving anticonvulsants.

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Tang et al Journal of ECT • Volume 00, Number 00, Month 2017

From the available clinical studies of efficacy of ECT given and anticonvulsant with an average duration of 11.4 seconds,
with anticonvulsants, only a large retrospective study of ECT for compared with 47.4 seconds after (Tables 1 and 2). We
schizophrenia showed a lower response rate associated with the recommend that clinicians discontinue benzodiazepines before
use of anticonvulsants: 3.7% of responders received anticonvul- initiating ECT or consider using BL ECT instead of RUL ECT
sants, compared with 17.9% of nonresponders.27 In a randomized, for their patients who are being treated with benzodiazepines or
rater-blinded, controlled trial of anticonvulsants during BL ECT at anticonvulsants that cannot be discontinued. With BL ECT,
1.5 times seizure threshold, patients were randomized to continue other factors need to be considered: an increased burden of
their anticonvulsant at full dose or half dose, or to discontinue it cognitive adverse effects22,45 but also the possibility of greater
for the course of treatment. There were no differences between effectiveness22 and faster speed of response.46
groups on clinical outcomes, although there was evidence of faster Anticonvulsants reduce ion channel activity, but they have
improvement with the full dose group.39 Also, there was no unclear effects on seizure parameters. Seizure threshold has been
difference in seizure duration between groups. Patients were found to be decreased,41 increased,25,42 or unrelated18,20 in pa-
not selected for diagnosis, but mania was the most common tients receiving concomitant ECT and anticonvulsant medications.
presentation. Significant limitations to this study include a lack Similar discrepancies can be found for the effect of anticonvul-
of standardization of dosages; 25% of participants not receiving sants on seizure duration.36–38 Nonetheless, an important finding
the dose they were randomized to receive; and the treating team of our review is that anticonvulsants did not decrease the effective-
being free to titrate the dosages after being informed of the ran- ness of ECT in 3 prospective clinical trials.39–41 However, in a ret-
domization status. Several other studies have been conducted in rospective study, a greater proportion of nonresponders were on
patients with bipolar disorder, who are the most likely to receive anticonvulsants compared with the responders.27 Of note, 2 of
mood-stabilizing anticonvulsants. In a double-blind randomized the prospective trials included only manic patients, and the third
controlled trial of 42 manic patients, there were no differences in one included patients with a mix of diagnosis, with mania being
clinical effect, number of ECT sessions, or length of stay in hos- the most common one.39 In many countries, ECT is primarily used
pital between those who discontinued or continued valproate in treatment resistant depression and is uncommonly used for ma-
(minimum of 750 mg/d).40 A similar study in a quasi-randomized nia.47 Depending on the original indication for anticonvulsants,
sample of 40 manic patients found no group differences in clinical their discontinuation may risk destabilization of an underlying sei-
improvement or seizure duration, but, surprisingly, the anticonvul- zure disorder or bipolar disorder. Pregabalin and gabapentin are
sant group had a lower seizure threshold.41 No other studies have also commonly used to treat chronic neuropathic pain conditions
found this unexpected decrease in seizure threshold. Lastly, a retro- and sometimes used to treat anxiety disorders. Clinicians should
spective chart review of 79 patients on anticonvulsants compared discuss with their patients the risks and benefits of changing
with 122 not on anticonvulsants, again did not find any differences existing medications based on their current efficacy and the indi-
in clinical improvement with ECT.42 However, being on an anticon- cation for ECT.
vulsant was associated with decreased seizure duration, increased With respect to the selection of electrode placement, it is im-
seizure threshold, and a higher incidence of failing to achieve sei- portant to note that the clinical studies reviewed here using unilat-
zures. These 3 studies are unique in their use of bifrontal electrode eral ECT stimulated the nondominant hemisphere determined
placement (with Virupaksha et al42 using a mixture of bifrontal and through handedness.48 More recent studies and guidelines only
bitemporal placements). The bifrontal placement has been less use RUL ECT.43 Therefore, the available evidence is best general-
commonly studied but is thought to have similar in efficacy to ized to the use of UL ECT that selects for the nondominant hemi-
bitemporal or RUL ECT.43 Before these studies, the available lit- sphere. Selection and titration of stimulus intensity are also
erature on anticonvulsants and ECT consisted of case reports and important factors for the clinical effectiveness of ECT. Unfortu-
small case series. In a review of 17 such publications, which col- nately, the available literature we reviewed predates many of the
lectively included 87 cases, only 9 (10.3%) of the cases had prob- seminal trials that have established the standard for RUL treatment
lems with seizure induction and side effects.44 Moreover, in titration to 6 times seizure threshold and BL ECT to 2 times sei-
only 2 (2.3%) of these cases, the anticonvulsants had to be zure threshold.23,45,49 None of studies of benzodiazepines or
completely discontinued, as the rest could be adequately treated anticonvulsants during ECT use stimulus titration methods relative
once the anesthetic agent was changed and/or the anticonvulsant to seizure threshold,16,24,36 and the efficacy of RUL ECT with con-
dose was reduced. comitant benzodiazepine use may have been underestimated. Future
studies using these medications under optimal stimulus intensities
in RUL ECT are needed to draw more definite conclusions.
DISCUSSION Based on the available evidence, concomitant use of benzo-
We presented a clinical case and reviewed the corresponding diazepines and anticonvulsants should be considered as relatively
literature on the use of benzodiazepines or anticonvulsants during contraindicated during ECT. Several other related factors remain
ECT. Benzodiazepines abort seizures or reduce seizure duration to be systematically examined. No studies have attempted to stan-
by activating the GABAergic system but do not raise seizure dardize the dosages of benzodiazepine or anticonvulsant medica-
threshold. The clinical effectiveness of RUL ECT, but not BL tions. Higher dosages are more likely to effect seizure quality,20
ECT, may be decreased in those using benzodiazepines.14,24,25 and decreasing dosages is a useful strategy to achieve better clin-
Only 1 study directly assessed the impact of benzodiazepines on ical response with ECT.39,44 Differences in dosing may account
RUL and BL ECT14; it did not find a significant difference in for the seemingly contradictory findings on seizure threshold,
mean seizure duration between the groups, although there was a seizure duration, and ECT efficacy in studies of concomitant
higher proportion of patients with at least 1 inadequate seizure anticonvulsant treatment. Studies examining a possible dose-
(ie, no seizure, partial seizure, or seizure lasting less than response relationship are required. Use of benzodiazepines or
25 seconds) in the benzodiazepine group compared with the anticonvulsant should also be balanced against other factors
non-benzodiazepine group. The mechanism behind the de- that affect seizure quality, such as the effects of increased age
creased efficacy of RUL ECT with concurrent benzodiazepine on seizure threshold19 or the concomitant use of other medica-
use remains unclear. Nonetheless, our patient, Mrs A, had short tions that can decrease seizure threshold such as certain antide-
seizure durations before discontinuation of her benzodiazepine pressant or antipsychotic medications.

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Journal of ECT • Volume 00, Number 00, Month 2017 Benzodiazepines and Anticonvulsants During ECT

Our case report appears to contradict the conclusions of the 7. Ottosson JO. Experimental studies of the mode of action of
literature when only focusing on the benzodiazepine and anticon- electroconvulsive therapy: introduction. Acta Psychiatr Scand Suppl. 1959;
vulsant that Mrs A received. Although she did receive benzodiaz- 35:5–6.
epines and an anticonvulsant during her first course of ECT, she 8. American Psychiatric Association. Committee on Electroconvulsive
was treated mostly with BL placement (6 BL sessions and 2 UL Therapy; Weiner RD. The practice of electroconvulsive therapy:
session). The discontinuation of most of these medications ap- recommendations for treatment, training, and privileging. A Task Force
peared to make a dramatic difference in ECT efficacy, greater than Report of the American Psychiatric Association. American Psychiatric
what was expected from our review. Therefore, it is possible that Publishing; 2001.
Mrs A's medications interfere with her seizures more than would 9. Abrams R. Electroconvulsive Therapy. Oxford University Press; 2002.
be expected from results of the literature, or there were other fac-
10. Maletzky BM. Seizure duration and clinical effect in electroconvulsive
tors that influenced seizure quality that were not identified in her
therapy. Compr Psychiatry. 1978;19:541–550.
first and second courses of ECT. Moreover, Mrs A was still receiv-
ing a small dose of pregabalin during her second course of ECT, 11. Strömgren L, Dahl J, Fjeldborg N, et al. Factors influencing seizure
but her overall relative dose was dramatically tapered down be- duration and number of seizures applied in unilateral electroconvulsive
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CONCLUSIONS Scand. 1985;71:269–271.
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13. Ottosson JO. Use and misuse of electroconvulsive treatment. Biol
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has still not been resolved clearly in the literature. Whereas 14. Pettinati HM, Stephens SM, Willis KM, et al. Evidence for less
avoiding antiseizure medications in a treatment using therapeutic improvement in depression in patients taking benzodiazepines during
seizures is intuitive, most available studies suggest that the clinical unilateral ECT. Am J Psychiatry. 1990;147:1029–1035.
effectiveness of ECT is not compromised by concomitant benzo- 15. Boylan LS, Haskett RF, Mulsant BH, et al. Determinants of seizure
diazepines or anticonvulsant use. Benzodiazepines are associated threshold in ECT: benzodiazepine use, anesthetic dosage, and other factors.
with decreased seizure duration, but only 1 study has reported that J ECT. 2000;16:3–18.
they increase seizure threshold. The available studies do not show 16. Sackeim HA, Devanand DP, Prudic J. Stimulus intensity, seizure threshold
that BL ECT is affected by benzodiazepines. Whereas evidence and seizure duration: impact on the efficacy and safety of electroconvulsive
exists for decreased effectiveness of UL ECT when benzodiaze- therapy. Psychiatr Clin North Am. 1991;14:803–843.
pines are used, no studies have used the current standard of 17. Coffey CE, Lucke J, Weiner RD, et al. Seizure threshold in
suprathreshold stimulation in RUL placement. No consistent con- electroconvulsive therapy: I. Initial seizure threshold. Biol Psychiatry.
clusions have been reached for the effect of anticonvulsants on 1995;37:713–720.
seizure parameters. Only 1 retrospective study reported an associ-
ation between a lower response rate and concomitant anticonvul- 18. van Waarde JA, van Oudheusden LJ, Verwey B, et al. Clinical predictors of
seizure threshold in electroconvulsive therapy: a prospective study.
sants and ECT. Thus, clinicians should only consider the use of
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