Prolonged bradycardia complicates antidepressive treatment with venlafaxine and ECT

[Electroconvulsive therapy in combination with psychotropic and non-psychotropic pharmacological treatments: Review of the literature and practical recommendations]

CONTEXT

Electro-convulsive therapy (ECT) is the most effective treatment for treatment resistant mood disorders and catatonia. ECT also appears to be an effective treatment in combination with clozapine in the context of treatment resistant schizophrenia spectrum disorders. Although increasingly codified (guidelines on indications, contraindications, methods of implementation), the practice of ECT still lacks consensual protocols. The concomitant use of psychotropic and/or non-psychotropic medication is a common situation when ECT treatment is considered. To our knowledge, there is to date no summary of studies or case reports in France, nor any proposal for guidelines concerning the management of medication of the patient to whom ECT sessions are offered. Indeed, several particularities must be considered. This article proposes to specify for each pharmacological class the possible interaction between ECT and medication. A first section of this article will be devoted to non-psychotropic treatments, and a second section to psychotropic treatments. A practical summary table is also provided.

METHOD

A review of the literature was conducted including all articles published prior to January 2019 referenced in Pub Med database, combining research with Medical Subject Headings "Electroconvulsive Therapy" and each following pharmacological class: "Cardiovascular Agents" "Bronchodilator Agents" "Bronchoconstrictor Agents" "Theophylline" "Anticoagulants" "Hypoglycemic Agents" "Insulin" "Potassium" "Benzodiazepines" "Valproic Acid" "Carbamazepine" "Lamotrigine" "Lithium" "Antidepressive Agents" "Antipsychotic Agents".

RESULTS

After reading the titles, abstracts and whole articles, then searching for additional articles in the references, 50 articles were selected. A summary table summarizing the main risks and proposing a course of action has been produced.

DISCUSSION

It is essential to take into account the specificity and the different physiological mechanisms involved in the ECT treatment in order to adjust the associated pharmacological treatments. The prescription for each molecule should be reviewed when ECT treatment is initiated.

Bradycardia caused by interaction of venlafaxine and cyclosporine: A case report

Background:

Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are prescribed widely for the treatment of depression, anxiety disorders and other psychiatric disorders. Although antidepressants are considered as a safety drug category but unexpected cardiovascular events have been reported as the most serious complications. The aim of this study was to introduce a case presentation on bradycardia due to the drug interference of venlafaxine and cyclosporine.

Case presentation:

The patient was a 38-year old woman diagnosed with systemic lupus erythematosus 5 years ago, who was admitted to a general educational hospital in northern Iran due to intensified rheumatologic symptoms and complaining about abdominal pain. Cyclosporine tab were administered to the patient, 50 mg twice daily. Two weeks after the administration of cyclosporine, the level of blood cyclosporine was checked. The patient became bradycardic after starting a single dose of venlafaxine (heart rate 52 ppm). Cardiac assessment showed no reason for bradycardia and it subsided after a drop of venlafaxine.

Conclusion:

As a result of the potential adverse drug interactions between cyclosporine and antidepressants such as venlafaxine, physicians should be aware of the possibility of bradycardia in the simultaneous prescription of these drugs in cases.

Concurrent Electroconvulsive Therapy and Bupropion Treatment

BACKGROUND

Bupropion is associated with a dose-dependent increased risk of seizures. Use of concomitant bupropion and electroconvulsive therapy (ECT) remains controversial because of an increased risk of prolonged seizures. This is the first systematic evaluation of the effect of bupropion on ECT.

METHODS

A case group (n = 119), patients treated with concomitant ECT and bupropion, was compared with an age and gender frequency-matched control group (n = 261), treated with only ECT. Electroconvulsive therapy treatment data including seizure length, number of treatments, and concurrent medications were extracted. Longitudinal mixed models examined ECT versus ECT + bupropion group differences over the course of treatments measured by seizure duration (electroencephalogram [EEG] and motor). Multivariable models examined the total number of treatments and first and last seizure duration. All models considered group differences with ECT treatment measures adjusted for age, gender, benzodiazepine treatment, lead placement, and setting.

RESULTS

Electroconvulsive therapy treatment with bupropion led to shorter motor seizure duration (0.047) and EEG seizure duration (P = 0.001). The number of ECT treatments (7.3 vs 7.0 treatments; P = 0.23), respectively, or the probability of a prolonged seizure (P = 0.15) was not significantly different. Benzodiazepine use was significantly more common in control subjects (P = 0.01).

LIMITATIONS

This is a retrospective analysis limited in part by unavailable variables (seizure threshold, nature of EEG and motor seizure monitoring, type of ECT device, dosing and formulation of bupropion, and duration of the current depressive illness).

CONCLUSIONS

This study revealed a significantly shorter duration in seizure length with ECT + concomitant bupropion, but not in the number of required treatments in those treated compared with ECT without bupropion. There remains a critical need to reevaluate the efficacy of concomitant use of psychotropic medications + ECT.

Brugada syndrome as a potential cardiac risk factor during electroconvulsive therapy (ECT)

A case of asystole (> 5 s) during electroconvulsive therapy (ECT) is reported in a patient who was subsequently diagnosed to have Brugada syndrome (BS). This hereditary sodium-channelopathy is characterized by typical, though intermittent, ECG abnormalities and carries a high risk of ventricular arrythmia and sudden cardiac death. The general occurence of BS is rare; however, it is more prevalent in men and in southeast Asian populations. As in the reported case, BS carriers may lack a telltale medical history and can present with normal ECG recordings. In these cases, BS can only be unmasked by repeated ECG recordings over time or by specialist cardiological examinations. To our knowledge, BS, which was first characterized in 1992, has not yet been in the focus of cardiac complications during ECT. However, as the presented case illustrates, this syndrome should be considered as a rare but potentially severe cardiac risk factor in the context of ECT.

The influence of concomitant antidepressant medication on safety, tolerability and clinical effectiveness of electroconvulsive therapy

BACKGROUND

A major problem in the treatment of severe depression is the onset latency until clinical improvement. So far, electroconvulsive therapy (ECT) is the most effective somatic treatment of depression. This holds especially true for treatment-refractory disturbances. However, not all patients respond to conventional unilateral ECT. In certain cases, subsequent clinical response can be achieved using bilateral or high-dose unilateral ECT. Also, a concomitant pharmacotherapy can be utilized to augment therapeutic effectiveness. Surprisingly, data in this field are widely lacking and only few studies showed advantages of an ECT/tricyclic antidepressant combination.

METHOD

We retrospectively evaluated 5482 treatments in 455 patients to investigate possible therapeutic advantages in combination therapies versus ECT monotherapy. Main outcome criteria were clinical effectiveness and tolerability. Moreover, treatment modalities and ictal neurophysiological parameters that might influence treatment outcome were analysed.

RESULTS

A total of 18.2% of our treatments were ECT monotherapy, 8.87% were done with one antidepressant. Seizure duration was unaffected by the most antidepressants. SSRI caused a lengthened seizure activity. Postictal suppression was lower in mirtazapine and higher in SSRI and SNRI treated patients. A significant enhancement of therapeutic effectiveness could be seen in the patient group receiving tricyclics, SSRI or mirtazapine. Serious adverse events were not recorded.

CONCLUSION

Our study supports the hypothesis that mirtazapine can be used to enhance the therapeutic effectiveness of ECT. Controlled studies are necessary to further investigate the possible advantages of ECT and pharmacotherapy combinations, especially the use of modern dually acting antidepressants which have proven their good effectiveness in treatment-resistant depression.

Excessive hypertension and pulmonary edema after electroconvulsive therapy

A 53-year-old right-handed man was scheduled to receive 6 treatments of electroconvulsive therapy (ECT) for intractable depression. He was being treated for long-standing hypertension with nadolol and had no history of cardiopulmonary disease. Six months previously, he received 6 nondominant, unilateral ECT treatments. During each of these treatments, his blood pressure increased transiently to as high as 250/150, but he experienced no adverse consequence. He commenced the current course of ECT with well-controlled blood pressure (145/90). During his first bilateral treatment, his blood pressure rose to 280/160, and pulmonary edema ensued. Clinically evident pulmonary edema after ECT is an uncommon event that rarely has been described in the literature.

The combined treatment of venlafaxine and ECT in treatment-resistant depressive patients

Objective To evaluate the efficacy and safety of the combination treatment of ECT and venlafaxine among treatment-resistant depressive patients. Methods We reviewed 21 depressive patients who were treated with a combination of electroconvulsive therapy (ECT) and venlafaxine. The indication of the ECT-venlafaxine treatment was inadequate response to at least one antidepressant trial of adequate doses and duration. Propofol was used as an anesthetic agent during ECT treatments. Results Ninety percent of the patients benefited from the combined treatment. The responsivity to the combination treatment was not associated with high dose of venlafaxine. In most of the patients, the combined treatment was safe and well tolerated. Adverse reactions occurred in 57% of the patients and included concentration difficulties (four patients), memory problems (seven patients) and headache (one patient). No asystole was observed. Treatment was safe with a low dose of venlafaxine equal to or lower than 225 mg/day. Conclusions It seems that treatment of ECT combined with low dose venlafaxine and propofol as anesthetic agent is effective and safe. This strategy may be a therapeutic option in treatment-resistant depressive patients.

Postictal asystole during ECT

BACKGROUND

Asystole is an uncommon but potentially fatal complication of electroconvulsive therapy (ECT). Several risks for poststimulus asystole have been described, but risks for asystole at other times have not.

METHOD

Two instances of ECT postictal asystole in healthy adult males are reported. Features in common are identified.

RESULTS

features shared differ from risk factors for poststimulus asystole. In common were adult but not geriatric age, male sex, good physical and cardiac health, mesomorphic habitus, anticholinergic pretreatment, vigorous ECT seizure, and low resting heart rate. Both patients showed postictal bradyarrhythmia at the previous ECT.

CONCLUSIONS

Postictal asystole has apparent similarities to postexertional asystole in athletes. The combination of higher pretreatment doses of an atropinic agent, a sympatholytic agent, and close monitoring of postictal cardiac rhythm should be considered with patients similar to ours, especially after occurrence of postictal bradyarrhythmia.