A 50-year-old man with bipolar I disorder on long-term lithium therapy is being prepared for an ECT session. What is the recommended management of lithium prior to the ECT session?

• A Continue lithium unchanged to prevent mood episode relapse.
• B Double the lithium dose to ensure adequate mood stabilization.
• C Switch lithium to valproate at least one week before ECT.
• D Withhold lithium for 24 to 48 hours prior to the ECT session. ✓

Explanation

Lithium is typically withheld for 24 to 48 hours before an ECT session. It can lower the seizure threshold unpredictably, prolong the seizure duration, and increase the risk of neurotoxicity when combined with ECT. Continuing it unchanged or doubling the dose raises the risk of delirium and prolonged seizures. Switching to valproate is not a standard requirement for ECT preparation.

Reference: Kaplan and Sadock's Comprehensive Textbook of Psychiatry, 11th ed.

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