Management and Prevention of Tardive Seizures

Tardive seizures are a rare but serious complication of electroconvulsive therapy, which can lead to early termination of an ECT course. A recent review by Warren et al discussed the reported prevalence of and risk factors for these events. While uncommon, our experience at Yale Psychiatric Hospital has revealed that tardive seizures occur more frequently than historically described, requiring urgent treatment for seizure termination and adjustments to subsequent ECT treatments. In our experience, most patients can safely continue ECT without further tardive seizures if appropriate adjustments are made. To our knowledge, there is no standardized algorithm for the management of tardive seizures, nor an explicit set of guidelines for risk mitigation if ECT will be continued. We provide both based on the data for management of status epilepticus, guided by our clinical experience and focused on short-acting agents appropriate for an ECT PACU setting. We also provide recommendations about when ECT should be paused and further workup pursued.