|Year : 2018 | Volume
| Issue : 6 | Page : 562-567
ECT in the postpartum period: A retrospective case series from a tertiary health care center in India
Sandeep Grover, Swapnajeet Sahoo, Subho Chakrabarti, Debashish Basu, Shubh M Singh, Ajit Avasthi
Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
|Date of Web Publication||9-Nov-2018|
Dr. Sandeep Grover
Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objective: To evaluate the clinical profile and effectiveness of ECT in females with postpartum onset psychiatric syndromes or worsening of psychiatric disorder during the postpartum period. Materials and Methods: A retrospective chart review was carried out to identify females who had received ECT during their postpartum period from January2004 to April 2017. Results: During the study period, 13 females in their postpartum period received ECT, which accounted for 2.24% of the total females (n = 578) who had received ECT and 1% of total patients who were administered ECT during this period. The most common clinical diagnosis was postpartum depression (n = 7; 53.86%). Three (23.1%) patients were diagnosed with bipolar disorder and had experienced a relapse during the postpartum period. Two (15.4%) patients were diagnosed with schizophrenia and 1 (7.7%) patient was diagnosed with postpartum psychosis/acute and transient psychotic disorder. ECT was considered as a treatment of choice in 9 (69.2%) patients. All the patients with depression or mania achieved clinical remission, and patients with psychotic disorders also had significant reduction in their symptoms. Cognitive complaints were reported by 4 (30.8%) patients, and aches and pains after ECT were reported by 7 (53.8%). Conclusion: ECT is a safe and effective treatment option in postpartum onset psychiatric syndromes or patients experiencing relapse or exacerbation of severe mental disorders during the postpartum period and is associated with a very good response rate with minimal or no complications.
Keywords: Depression, electroconvulsive therapy, postpartum
|How to cite this article:|
Grover S, Sahoo S, Chakrabarti S, Basu D, Singh SM, Avasthi A. ECT in the postpartum period: A retrospective case series from a tertiary health care center in India. Indian J Psychol Med 2018;40:562-7
|How to cite this URL:|
Grover S, Sahoo S, Chakrabarti S, Basu D, Singh SM, Avasthi A. ECT in the postpartum period: A retrospective case series from a tertiary health care center in India. Indian J Psychol Med [serial online] 2018 [cited 2018 Dec 15];40:562-7. Available from: http://www.ijpm.info/text.asp?2018/40/6/562/243809
| Introduction|| |
As per World Health Organization, postpartum period is the period that begins immediately after the birth of a child and extends for about 6 weeks. However, for the purpose of defining various psychiatric syndromes, which have their onset in the postpartum period, the cutoff for the onset of the disorder is taken to be 3 months but can extend up to even 1 year., Three types of postpartum onset psychiatric disorders have been identified, that is, postpartum blues, postpartum depression, and postpartum psychosis. Apart from new-onset psychiatric disorders, the postpartum period is also associated with relapse of severe mental disorders like schizophrenia, bipolar disorder (BD), and recurrent depressive disorders.,, Postpartum period is a very critical period that can either lead to the development of new psychiatric disorders or can lead to instability in previously diagnosed severe mental illness. The relapse of symptoms during the postpartum period can impose a significant management challenge during this vulnerable period.
Although adequate and urgent treatment is necessary when one develops postpartum onset psychiatric syndrome or experiences a relapse of preexisting psychiatric conditions, use of pharmacological agents have certain limitations like lag period in the onset of therapeutic effect, drug interactions, and the risk of secretion in breast milk leading to adverse consequences for the newborn. When required, use of electroconvulsive therapy (ECT) during the postpartum period is often regarded as a safe and effective treatment strategy. The existing literature on the use of ECT in the postpartum period is limited to a few case reports/series,,,,,, retrospective register-based studies,,,, and a few prospective studies., In a review of literature that included data published up to September 2014, authors reported the existence of eight case reports and eight studies. These reports varied in defining the onset of postpartum-related psychiatric syndromes, with some taking 3 months as the cutoff and others taking onset up to 11 months., Most studies had reported positive outcome with ECT in the majority of the patients. One prospective study included in that review evaluated 78 females with postpartum psychosis and reported use of ECT in 34 (43.6%) cases. The common indications for ECT were the presence of catatonia, augmentation of medications, and the presence of suicidality. A few more studies have been published since the publication of that review. A recent retrospective study, which evaluated catatonia among female with postpartum psychosis in a mother-baby inpatient psychiatry unit, reported the usefulness of ECT in 19 females who did not respond to lorazepam trial. Another retrospective study reported that 3.7% of total ECTs were administered to patients with postpartum psychosis. A retrospective study which evaluated the use of ECT in females from Turkey reported that only 3.24% of females admitted to a psychiatric inpatient unit received ECT, of which 20% of ECTs were used during the postpartum period.
From the above literature, it is apparent that the literature is limited with regards to the use of ECT in patients with postpartum onset illness or those experiencing a relapse during the postpartum period. There are several challenges in using ECT in the postpartum period vis-à-vis routine patients. Some of these issues include the use of anesthesia in the postpartum period, issues related to breastfeeding, need for quick resolution of symptoms, and ECT-related memory/cognitive deficits that can affect child care and mother–child bonding. In view of limited literature on the topic, present retrospective chart review aimed to evaluate the effectiveness and safety of ECT in patients with postpartum onset illness or those experiencing a relapse during the postpartum period.
| Materials and Methods|| |
This study was done in a multispecialty, tertiary care center in North India. The study was approved by the Ethics Committee of the institute.
For this study, the ECT register of the department was used to identify the patients who received ECT for postpartum onset illness or those experiencing a relapse during the postpartum period. At the first step, ECT register for the period January 2004–April 2017 was screened to identify all the female patients who received ECT. Their treatment records were retrieved and reviewed. Only those cases who had postpartum onset illness (i.e., onset of a psychiatric syndrome or a relapse within 3 months of childbirth) were taken up for the study. Patients who were started on ECT during the pregnancy and were continued through to postpartum were excluded. Descriptive statistics were used to analyze the data. SPSS version 14 was used for the analysis. Descriptive statistics in mean and standard deviation were calculated for the continuous variables; and frequency and percentages for the categorical variables.
| Results|| |
During the study period, 1,302 patients received ECT, of which 578 (44.39%) were females. ECT was used in only 13 (2.24%) females experiencing postpartum onset illness or those experiencing a relapse during the postpartum period, which was only 1% of the total number of patients who received ECT. These patients formed the study sample.
Sociodemographic and clinical details of the patients included in the study are provided in [Table 1].
ECT was considered as a treatment of choice, taking the clinical picture into account, in approximately 70% of the patients (n = 9; 69.2%). Various indications for the use of ECT are provided in [Table 2].
The mean number of effective ECTs received by each patient was 7.30 (SD, 2.65; range, 3–12) and other ECT related details are given in [Table 2].
Effectiveness and safety of ECT
All patients showed improvement with ECT to the extent that all patients with depression and mania achieved clinical remission [Table 3]. Patients with psychotic disorders also had a significant reduction in the rating scales. In all cases, ECT was stopped because of achieving a plateau of response. No patient required maintenance ECTs. No immediate complications were experienced in any case, but delayed complications in the form of cognitive complaints were reported by 4 (30.8%) patients, and aches and pains after ECT were reported by 7 (53.8%) patients. All the babies were breastfed during the postpartum period, and none of the babies had any observable/reported adverse effects.
|Table 3: Details of all the 13 patients who received ECT during postpartum period|
Click here to view
| Discussion|| |
The onset of psychiatric symptoms during the postpartum period requires a quick and effective relief as it hampers both maternal and infant health as well as mother–infant bonding. Long-term untreated psychosis/depression/mania during the postpartum period can not only lead to a worse prognosis for the patient but also could lead to behavioral problems and difficult temperament in the children., Use of psychotropic medications is associated with a lag time for response and adverse effects for both the mother and the newborn.
ECT can be considered as a safe option in the postpartum period. However, there is limited data on the effectiveness of ECT in females during the postpartum period.,,,, Present study adds to the limited literature on this topic.
The present study showed that in a span of about 13.5 years, female patients comprised of about 45% of total patients receiving ECT and of them, only 2.24% received ECT during the postpartum period. Previous studies regarding the percentage of females receiving ECTs have also shown that only half of the subjects receiving ECTs are females and more females than males are referred for ECT. However, these findings are contrary to some of the studies that have shown females to form a very small proportion of patients receiving ECT. Studies have also shown that about 20% of the females receiving ECTs are usually in their postpartum period and the diagnosis is more often postpartum psychosis and postpartum depression., In contrast, in our sample, females receiving ECT in the postpartum period formed only a very small proportion of all patients receiving ECT and females receiving ECT. These differences possibly reflect differences in the patient profile seen at various centers and possible cultural differences in acceptance of ECT.
Existing literature suggests that most patients who develop postpartum onset psychiatric syndromes are primipara and that these disorders are mostly seen during the third decade of life. These findings possibly suggest that primipara females in the third decade of life are possibly at greater risk of developing psychiatric disorders.,, Most of our patients who received ECT were also in their third decade of life and primipara (after their first childbirth). A few studies had detected an association of birth of a female baby with the development of postpartum psychosis. However, in the present study, most of the subjects had given birth to a male baby. These findings possibly suggest that postpartum onset of the psychiatric syndrome has more to do with the biological, hormonal changes rather than just the psychosocial issues.
Most patients in the present study who received ECT had postpartum onset illness, mainly postpartum depression. Overall, depression was the most common reason for the use of ECT and in more than half of the cases and depression was associated with psychotic symptoms. Existing literature on the use of ECT in postpartum psychiatric disorders also suggests that depression is the most common reason for the use of ECT in the postpartum psychiatric syndromes.,, Existing literature suggests that depression, suicidality, and catatonia are the most common indications for the use of ECT in patients with postpartum psychiatric syndromes.,, In the present study too, similar indications were noted for giving ECT. Further, in about more than two thirds of our cases, ECT was considered as a treatment option to achieve early treatment response. Previous studies also suggest that ECT is considered during the postpartum to achieve early treatment response.,,,,
All our patients had significant improvement with the mean number of 7.3 ECTs. Existing data also suggest that patients with postpartum depression and psychosis respond rapidly to ECT with an early and complete remission of symptoms.,,, These findings suggest that ECT should be considered as an option for management of severe postpartum onset disorders or for patients with severe mental disorders experiencing a relapse in the postpartum period.
The main adverse effects reported by some of our patients were aches and pains and cognitive disturbances, which were self-limited. These are common adverse effects of ECT in any age group, and similar findings have been reported by previous studies among patients receiving ECT for postpartum mood and psychotic disorders.,
Small sample size and retrospective nature of data are the obvious limitations of the present study, and prospective studies with a large sample are required to address the safety and efficacy of ECT in the postpartum period. No formal standardized instrument was used for assessment of cognitive functions, and these were enquired based on subjective complaints of memory disturbances by the patients.
| Conclusion|| |
To conclude, the present study suggests that ECT is a safe and effective treatment option in managing postpartum onset psychiatric syndrome or patients experiencing relapse or exacerbation of severe mental disorders during the postpartum period.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Forray A, Ostroff RB. The use of electroconvulsive therapy in postpartum affective disorders. J ECT 2007;23:188-93.
Robertson E, Celasun N, Stewart DE. Risk factors for postpartum depression. In: Stewart DE, Robertson E, Dennis CL, Grace SL, Wallington T, editors. Postpartum depression: Literature review of risk factors and interventions. Toronto: University Health Network Women's Health Program, Toronto public health; 2003.
Tomruk NB, Saatcioglu PDO. Treatment Challenges in Schizophrenia in the Perinatal Period and Infanticide. KlinPsikofarmakolBül 2010;20:266-8.
Wesseloo R, Kamperman AM, Munk-Olsen T, Pop VJM, Kushner SA, Bergink V. Risk of Postpartum Relapse in Bipolar Disorder and Postpartum Psychosis: A Systematic Review and Meta-Analysis. Am J Psychiatry 2016;173:117-27.
Di Florio A, Forty L, Gordon-Smith K, Heron J, Jones L, Craddock N, et al
. Perinatal episodes across the mood disorder spectrum. JAMA Psychiatry 2013;70:168-75.
Robertson E, Jones I, Haque S, Holder R, Craddock N. Risk of puerperal and non-puerperal recurrence of illness following bipolar affective puerperal (post-partum) psychosis. Br J Psychiatry 2005;186:258-9.
Eberhard-Gran M, Eskild A, Opjordsmoen S. Use of psychotropic medications in treating mood disorders during lactation: Practical recommendations. CNS Drugs 2006;20:187-98.
Focht A, Kellner CH. Electroconvulsive therapy (ECT) in the treatment of postpartum psychosis. J ECT 2012;28:31-3.
Stanworth HM. After-care of puerperal psychosis in the community. Nurs Times 1982;78:922-5.
Robinson GE, Stewart DE. Postpartum psychiatric disorders. CMAJ 1986;134:31-7.
Kisa C, Yildirim SG, Aydemir C, Cebeci S, Goka E. Prolonged electroconvulsive therapy seizure in a patient taking ciprofloxacin. J ECT 2005;21:43-4.
Levy Y, Austin M-P, Halliday G. Use of ultra-brief pulse electroconvulsive therapy to treat severe postnatal mood disorder. Australas Psychiatry 2012;20:429-32.
Gressier F, Rotenberg S, Cazas O, Hardy P. Postpartum electroconvulsive therapy: Asystematic review and case report. Gen Hosp Psychiatry 2015;37:310-4.
Reed P, Sermin N, Appleby L, Faragher B. A comparison of clinical response to electroconvulsive therapy in puerperal and non-puerperal psychoses. J Affect Disord 1999;54:255-60.
Katona CL. Puerperal mental illness: Comparisons with non-puerperal controls. Br J Psychiatry 1982;141:447-52.
Protheroe C. Puerperal Psychoses: A Long Term Study 1927-1961. Br J Psychiatry 1969;115:9-30.
Nahar A, Kondapuram N, Desai G, Chandra PS. Catatonia among women with postpartum psychosis in a Mother-Baby inpatient psychiatry unit. Gen Hosp Psychiatry 2017;45:40-3.
Agrawal P, Bhatia MS, Malik SC. Post Partum Psychosis: A Clinical Study. Int JSoc Psychiatry 1997;43:217-22.
Babu GN, Thippeswamy H, Chandra PS. Use of electroconvulsive therapy (ECT) in postpartum psychosis—a naturalistic prospective study. Arch Womens Ment Health 2013;16:247-51.
Martin ME. Puerperal mental illness; a follow-up study of 75 cases. Br Med J 1958;2:773-7.
Subedi S, Aich TK, Sharma N. Use of ECT in Nepal: A one year study from the country's largest psychiatric facility. J Clin Diagn Res 2016;10:VC01-4.
Özdemir A, Poyraz CA, Erten E, Çırakoğlu E, Tomruk N. Electroconvulsive Therapy in Women: A retrospective study from a mental health hospital in Turkey. Psychiatr Q 2016;87:769-79.
Forman DR, O'Hara MW, Stuart S, Gorman LL, Larsen KE, Coy KC. Effective treatment for postpartum depression is not sufficient to improve the developing mother-child relationship. DevPsychopathol 2007;19:585-602.
Tronick E, Reck C. Infants of depressed mothers. Harv Rev Psychiatry 2009;17:147-56.
Bloch Y, Ratzoni G, Sobol D, Mendlovic S, Gal G, Levkovitz Y. Gender differences in electroconvulsive therapy: A retrospective chart review. J Affect Disord 2005;84:99-102.
Vesga-Lopez O, Blanco C, Keyes K, Olfson M, Grant BF, Hasin DS. Psychiatric Disorders in Pregnant and Postpartum Women in the United States. Arch Gen Psychiatry 2008;65:805-15.
Rai S, Pathak A, Sharma I. Postpartum psychiatric disorders: Early diagnosis and management. Indian J Psychiatry 2015;57:S216-21.
Doucet S, Jones I, Letourneau N, Dennis C-L, Blackmore ER. Interventions for the prevention and treatment of postpartum psychosis: A systematic review. Arch Womens Ment Health 2011;14:89-98.
Fitelson E, Kim S, Baker AS, Leight K. Treatment of postpartum depression: Clinical, psychological and pharmacological options. Int J Womens Health 2010;3:1-14.
[Table 1], [Table 2], [Table 3]