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

Rikinkumar S. Patel, Anil Bachu, Nagy A. Youssef

Research output: Contribution to journalArticle

Abstract

Background: Lithium is a helpful adjunct to patients undergoing ECT. However, only case reports and limited data suggest increase risk of delirium. Thus, this continues to be a controversial issue. Objective: In this study, we examine 1) The association and odds of delirium and cognitive problems with ECT and lithium (ECT + Li) combination compared to ECT alone, 2) If positively associated, would this association vary by both type of mood episode and type of disorder? Methods: A national sample of 64,728 adult psychiatric inpatients across the US (identified from a total data of about 70 million total discharges annually) was analyzed using linear-by-linear association and logistic regression to assess the odds ratio (OR) for delirium and cognitive impairment for those treated with lithium (N = 158), ECT (N = 64148), or ECT + Li (N = 422) after adjusting for demographics and psychiatric diagnoses. Results: The prevalence of delirium was higher in the ECT + Lithium group (5.7%) vs. ECT only (0.6%) or lithium only groups (0%). Patients managed with ECT + Lithium have 11.7-fold higher odds (95% CI 7.55–17.99, P < 0.001) of delirium compared to ECT alone. In the ECT + Li group, delirium prevalence was 7.8% in unipolar depression, 3.4% in bipolar depressed, 0% in bipolar mania. Conclusion: These results are surprising given the fading concern about delirium association with ECT + lithium combination. The high odds in the combination group warrant clinical caution, use of lower lithium doses (if combinations cannot be avoided), and vigilance regarding early signs of delirium. These results warrant replication in future studies.

Original languageEnglish (US)
Pages (from-to)15-19
Number of pages5
JournalBrain Stimulation
Volume13
Issue number1
DOIs
StatePublished - Jan 1 2020

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Electroconvulsive Therapy
Delirium
Lithium
Depressive Disorder
Mood Disorders
Bipolar Disorder
Mental Disorders
Psychiatry
Inpatients
Linear Models
Logistic Models
Odds Ratio
Demography

Keywords

  • Bipolar disorder
  • Cognitive side effects
  • Delirium
  • Depression
  • Electroconvulsive therapy
  • Lithium
  • Major depressive disorder
  • Treatment-resistant depression

ASJC Scopus subject areas

  • Biophysics
  • Neuroscience(all)
  • Clinical Neurology

Cite this

@article{ec5469042d7d4c7aa398703fe9ed9a19,
title = "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",
abstract = "Background: Lithium is a helpful adjunct to patients undergoing ECT. However, only case reports and limited data suggest increase risk of delirium. Thus, this continues to be a controversial issue. Objective: In this study, we examine 1) The association and odds of delirium and cognitive problems with ECT and lithium (ECT + Li) combination compared to ECT alone, 2) If positively associated, would this association vary by both type of mood episode and type of disorder? Methods: A national sample of 64,728 adult psychiatric inpatients across the US (identified from a total data of about 70 million total discharges annually) was analyzed using linear-by-linear association and logistic regression to assess the odds ratio (OR) for delirium and cognitive impairment for those treated with lithium (N = 158), ECT (N = 64148), or ECT + Li (N = 422) after adjusting for demographics and psychiatric diagnoses. Results: The prevalence of delirium was higher in the ECT + Lithium group (5.7{\%}) vs. ECT only (0.6{\%}) or lithium only groups (0{\%}). Patients managed with ECT + Lithium have 11.7-fold higher odds (95{\%} CI 7.55–17.99, P < 0.001) of delirium compared to ECT alone. In the ECT + Li group, delirium prevalence was 7.8{\%} in unipolar depression, 3.4{\%} in bipolar depressed, 0{\%} in bipolar mania. Conclusion: These results are surprising given the fading concern about delirium association with ECT + lithium combination. The high odds in the combination group warrant clinical caution, use of lower lithium doses (if combinations cannot be avoided), and vigilance regarding early signs of delirium. These results warrant replication in future studies.",
keywords = "Bipolar disorder, Cognitive side effects, Delirium, Depression, Electroconvulsive therapy, Lithium, Major depressive disorder, Treatment-resistant depression",
author = "Patel, {Rikinkumar S.} and Anil Bachu and Youssef, {Nagy A.}",
year = "2020",
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doi = "10.1016/j.brs.2019.08.012",
language = "English (US)",
volume = "13",
pages = "15--19",
journal = "Brain Stimulation",
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TY - JOUR

T1 - 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

AU - Patel, Rikinkumar S.

AU - Bachu, Anil

AU - Youssef, Nagy A.

PY - 2020/1/1

Y1 - 2020/1/1

N2 - Background: Lithium is a helpful adjunct to patients undergoing ECT. However, only case reports and limited data suggest increase risk of delirium. Thus, this continues to be a controversial issue. Objective: In this study, we examine 1) The association and odds of delirium and cognitive problems with ECT and lithium (ECT + Li) combination compared to ECT alone, 2) If positively associated, would this association vary by both type of mood episode and type of disorder? Methods: A national sample of 64,728 adult psychiatric inpatients across the US (identified from a total data of about 70 million total discharges annually) was analyzed using linear-by-linear association and logistic regression to assess the odds ratio (OR) for delirium and cognitive impairment for those treated with lithium (N = 158), ECT (N = 64148), or ECT + Li (N = 422) after adjusting for demographics and psychiatric diagnoses. Results: The prevalence of delirium was higher in the ECT + Lithium group (5.7%) vs. ECT only (0.6%) or lithium only groups (0%). Patients managed with ECT + Lithium have 11.7-fold higher odds (95% CI 7.55–17.99, P < 0.001) of delirium compared to ECT alone. In the ECT + Li group, delirium prevalence was 7.8% in unipolar depression, 3.4% in bipolar depressed, 0% in bipolar mania. Conclusion: These results are surprising given the fading concern about delirium association with ECT + lithium combination. The high odds in the combination group warrant clinical caution, use of lower lithium doses (if combinations cannot be avoided), and vigilance regarding early signs of delirium. These results warrant replication in future studies.

AB - Background: Lithium is a helpful adjunct to patients undergoing ECT. However, only case reports and limited data suggest increase risk of delirium. Thus, this continues to be a controversial issue. Objective: In this study, we examine 1) The association and odds of delirium and cognitive problems with ECT and lithium (ECT + Li) combination compared to ECT alone, 2) If positively associated, would this association vary by both type of mood episode and type of disorder? Methods: A national sample of 64,728 adult psychiatric inpatients across the US (identified from a total data of about 70 million total discharges annually) was analyzed using linear-by-linear association and logistic regression to assess the odds ratio (OR) for delirium and cognitive impairment for those treated with lithium (N = 158), ECT (N = 64148), or ECT + Li (N = 422) after adjusting for demographics and psychiatric diagnoses. Results: The prevalence of delirium was higher in the ECT + Lithium group (5.7%) vs. ECT only (0.6%) or lithium only groups (0%). Patients managed with ECT + Lithium have 11.7-fold higher odds (95% CI 7.55–17.99, P < 0.001) of delirium compared to ECT alone. In the ECT + Li group, delirium prevalence was 7.8% in unipolar depression, 3.4% in bipolar depressed, 0% in bipolar mania. Conclusion: These results are surprising given the fading concern about delirium association with ECT + lithium combination. The high odds in the combination group warrant clinical caution, use of lower lithium doses (if combinations cannot be avoided), and vigilance regarding early signs of delirium. These results warrant replication in future studies.

KW - Bipolar disorder

KW - Cognitive side effects

KW - Delirium

KW - Depression

KW - Electroconvulsive therapy

KW - Lithium

KW - Major depressive disorder

KW - Treatment-resistant depression

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U2 - 10.1016/j.brs.2019.08.012

DO - 10.1016/j.brs.2019.08.012

M3 - Article

C2 - 31492631

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VL - 13

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JO - Brain Stimulation

JF - Brain Stimulation

SN - 1935-861X

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