Over the past four decades, a variety of pharmacological augmentation strategies have been used in electroconvulsive therapy (ECT). Their goal has been to enhance therapeutic effects and seizure manifestations, or to minimize cognitive effects. Although they are not intended to affect outcome or other clinical parameters, medications taken during ECT may also impact on safety and efficacy. There is a large literature in epileptology on how pharmacologic agents affect seizure physiology. We review the clinical literature on augmentation strategies in ECT, with a synopsis of relevant preclinical studies, and seek to relate the pharmacological effects on seizure parameters to critical clinical variables in ECT.