# Situation: A 58-year-old woman with severe major depressive disorder with psychotic features has refused most food and fluids for 4 days and is scheduled for a course of electroconvulsive therapy (ECT) with right unilateral electrode placement. She has controlled hypertension and no cardiac, neurologic, or pulmonary disease. She has given written informed consent. On the evening before the first treatment, the nurse reviews her medication orders. Which order should the nurse bring to the prescriber's attention before the treatment?

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> subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations

## 문제

Situation: A 58-year-old woman with severe major depressive disorder with psychotic features has refused most food and fluids for 4 days and is scheduled for a course of electroconvulsive therapy (ECT) with right unilateral electrode placement. She has controlled hypertension and no cardiac, neurologic, or pulmonary disease. She has given written informed consent.

On the evening before the first treatment, the nurse reviews her medication orders. Which order should the nurse bring to the prescriber's attention before the treatment?

## 보기

1. Amlodipine 5 mg orally every morning
2. Sertraline 100 mg orally every morning
3. Olanzapine 10 mg orally at bedtime
4. Lorazepam 2 mg orally at bedtime **✔ 정답**

**정답: 4**

## 해설

Benzodiazepines and anticonvulsants raise the seizure threshold, so an adequate therapeutic seizure may not occur; the prescriber usually reduces or holds them before ECT. Antidepressants and antipsychotics are commonly continued, and antihypertensives are given with a sip of water on the morning of treatment.

## 심화 해설

Clinical context

This patient is scheduled for right unilateral ECT after four days of severely reduced oral intake. Because she has been refusing most food and fluids, medication absorption and the risk of dehydration-related complications are already relevant, but the immediate pre-ECT concern is whether any current medication will interfere with seizure induction. The prescriber must be notified when a drug is likely to raise the seizure threshold enough to prevent an adequate therapeutic seizure.

Why lorazepam is the priority

Lorazepam is a benzodiazepine. Benzodiazepines enhance GABA-mediated inhibition in the central nervous system, which directly raises the seizure threshold and can shorten or prevent the seizure needed for ECT efficacy. If the seizure is inadequate, the treatment may be repeated at a higher stimulus or the entire session may be considered unsuccessful. The prescriber typically reduces or holds the benzodiazepine before each treatment, and in some settings flumazenil has been used to reverse benzodiazepine effects when holding the drug is not possible [4].

Watch out! The issue is not that lorazepam causes seizures. The issue is the opposite: it suppresses the very seizure ECT is trying to produce. A patient who is calm at bedtime may still have enough benzodiazepine effect the next morning to blunt the ECT seizure.

Why the other medications are less concerning

Amlodipine is an antihypertensive. Because this patient has controlled hypertension and no cardiac disease, the usual practice is to give the morning antihypertensive with a small sip of water before ECT to avoid a treatment-related blood pressure surge. Holding it abruptly could be more dangerous than giving it.

Sertraline is an SSRI antidepressant. Antidepressants are commonly continued during an ECT course. Although some antidepressants can lower the seizure threshold, this is not the primary safety concern for a patient with no seizure history, and continuing treatment of the underlying depression is generally preferred.

Olanzapine is a second-generation antipsychotic. In psychotic depression, the antipsychotic is usually continued during ECT because stopping it risks worsening psychosis. Antipsychotics can affect seizure threshold in different directions depending on the drug and dose, but they are not routinely held in the same way benzodiazepines are .

Seizure threshold and medication effects

The goal of ECT stimulus titration is to find the lowest electrical dose that produces an adequate seizure. Medications that raise the seizure threshold force the treatment team to use a higher stimulus, and if the threshold is raised too much, no adequate seizure occurs at all. Medications that lower the threshold can theoretically prolong seizures, but the more common pre-ECT adjustment is reducing threshold-raising drugs such as benzodiazepines and anticonvulsants .

| Medication class | Typical effect on seizure threshold | Pre-ECT action |
| --- | --- | --- |
| Benzodiazepines (lorazepam) | Markedly raises threshold, shortens seizure | Usually held or reduced before ECT |
| Anticonvulsants | Raises threshold | Usually held or reduced before ECT |
| Antidepressants (SSRIs, bupropion) | Variable; bupropion may lower threshold | Often continued; bupropion requires caution |
| Antipsychotics (olanzapine) | Variable effect on threshold and duration | Often continued for psychotic symptoms |
| Antihypertensives (amlodipine) | Minimal direct effect on seizure threshold | Given with sip of water on treatment morning |

Applying this to the patient

The patient has severe major depressive disorder with psychotic features. Her sertraline and olanzapine are treating the very conditions that made ECT necessary, so abruptly stopping them the night before treatment would risk clinical deterioration without a clear seizure-related benefit. Amlodipine is needed for blood pressure control during the procedure. Lorazepam, however, is a symptomatic medication that can be safely held or reduced for one night to improve the chance of an adequate therapeutic seizure [4]. The nurse should bring the lorazepam order to the prescriber's attention so the dose can be adjusted before the first ECT session.References (research sources)

- [4]Effectiveness and Safety of Flumazenil Augmentation During Electroconvulsive Therapy.Research articleGistelinck L, Van de Velde N, Tandt H, Verslype P, Lemmens G (2024) · DOI: 10.1097/YCT.0000000000001003

## 임상 시나리오

Pre-ECT Medication ReviewHold benzodiazepines to ensure an adequate therapeutic seizure
Benzodiazepines such as lorazepam raise the seizure threshold and can prevent an adequate therapeutic seizure during ECT. The prescriber usually holds or reduces the dose before each treatment.

Antidepressants and antipsychotics are commonly continued during ECT. Antihypertensives may be given with a sip of water on the morning of treatment.

CautionThe concern is not that lorazepam causes seizures, but that it suppresses the seizure ECT is trying to produce. Even a bedtime dose may blunt the seizure the next morning.

## 핵심 개념

- **Seizure threshold** — The minimum electrical stimulus needed to induce a seizure; drugs like benzodiazepines raise it, making therapeutic seizures harder to achieve.
- **Benzodiazepine** — A class of GABA-enhancing drugs that suppress seizure activity and are typically held or reduced before ECT.
- **Electroconvulsive therapy (ECT)** — A procedure using electrical stimulation to induce a controlled seizure for treatment of severe depression and other psychiatric conditions.
- **Right unilateral electrode placement** — An ECT technique placing electrodes on one side of the head, associated with fewer cognitive side effects.
- **Therapeutic seizure** — A seizure of adequate duration and quality during ECT that is considered necessary for treatment efficacy.

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