Rehospitalization of Postpartum Depression and Psychosis After Electroconvulsive Therapy: A Population-Based Study With a Matched Control Group

Treatment of postpartum psychotic- or mood disorder requiring admission: A nationwide study from Denmark

BACKGROUND

Postpartum psychotic- or mood disorders are psychiatric emergencies associated with risk of suicide and infanticide. Except from case reports, there are only few descriptions of its treatment. Therefore, we aimed to describe the treatment of women admitted with postpartum psychotic- or mood disorder in Denmark with emphasis on the use of electroconvulsive therapy (ECT).

METHODS

We conducted a register-based cohort study of all women with incident postpartum psychotic- or mood disorder (no prior diagnoses of psychotic- or mood disorder or treatment with ECT) requiring admission in the period from 2011 to 2018. For these patients, we described the treatment and the 6-month readmission risk.

RESULTS

We identified 91 women with postpartum psychotic- or mood disorder with a median admission length of 27 days (interquartile range: 10-45). Of those, 19% received ECT with a median time from admission to first ECT of 10 days (interquartile range: 5-16). The median number of ECT sessions was eight (interquartile range: 7-12). In the 6 months following discharge, 90% of the women received some form of psychopharmacological treatment (62% antipsychotics, 56% antidepressants, 36% anxiolytics/sedatives, 19% lithium, and 9% mood stabilizing antiepileptics), and 31% were readmitted.

CONCLUSION

Psychiatric admission for incident postpartum psychotic- or mood disorder is rare in Denmark. Among those admitted, ECT and psychopharmacological treatment is commonly used. The 6-month readmission risk is high, warranting close follow-up. The fact that there is no international consensus on the optimal treatment of postpartum psychotic- or mood disorder is problematic and calls for action.

Use of electroconvulsive therapy during postpartum: A retrospective chart review

Background

There is limited data on use of electroconvulsive therapy (ECT) for management of psychiatric disorders during the postpartum period from India.

Aim

We aimed to assess the demographic and clinical profile of patients receiving ECT during the postpartum period for various psychiatric disorders using a retrospective study design.

Methods

ECT register of the department was reviewed for the period of January 2019 to December 2023 to identify the patients who received ECT during the postpartum period. The treatment records of these patients were evaluated to extract the demographic and clinical profile.

Results

During the study period, 10 patients received ECT during the postpartum period. The mean age of the study sample was 27 (standard deviation [SD]: 2.9) years. Majority of the patients were inpatients (70%) at the time of receiving ECT. Five patients were diagnosed with first-episode depression with postpartum onset, and two patients had postpartum-onset psychotic disorder. One patient was diagnosed with recurrent depressive episode and one with bipolar disorder, current episode mania with psychotic symptom, at the time of receiving ECT. The mean number of ECTs during the ECT course was 6.7 (SD: 3.09). Nine out of the 10 patients showed good response to ECT.

Conclusion

Although ECT is less frequently used for management of postpartum psychiatric disorders, its use is associated with significant clinical improvement.

Postpartum Psychosis: A Proposed Treatment Algorithm

Background

Postpartum psychosis (PPP) is a psychiatric emergency that generally warrants acute inpatient care. PPP is marked by the sudden onset of affective and psychotic symptoms with a rapid deterioration in mental state. Evidence suggests that PPP is a discrete disorder on the bipolar disorder spectrum with a distinct treatment profile and prognosis.

Methods

We conducted a PubMed database search for various terms involving PPP and its treatment and included peer-reviewed articles published in English.

Objective

To provide a treatment algorithm for the management of PPP based on available evidence.

Results

Pharmacological therapy is the mainstay of PPP management in the acute phase. Evidence points to a combination of antipsychotics and lithium in the acute treatment of PPP. Electroconvulsive therapy can offer a rapid treatment response where required. Lithium appears to have the best evidence for relapse prevention and prophylaxis in PPP. Psychoeducation is essential and psychosocial interventions used in bipolar disorder may be effective in PPP.

Conclusion

Early detection and prompt treatment with antipsychotics and lithium, followed by maintenance treatment with lithium, is associated with a favourable prognosis in PPP.Reprinted from J Psychopharmacol 2023; 37:960-970, with permission from Sage Journals. Copyright © 2023.

Postpartum psychosis: A proposed treatment algorithm

BACKGROUND

Postpartum psychosis (PPP) is a psychiatric emergency that generally warrants acute inpatient care. PPP is marked by the sudden onset of affective and psychotic symptoms with a rapid deterioration in mental state. Evidence suggests that PPP is a discrete disorder on the bipolar disorder spectrum with a distinct treatment profile and prognosis.

METHODS

We conducted a PubMed database search for various terms involving PPP and its treatment and included peer-reviewed articles published in English.

OBJECTIVE

To provide a treatment algorithm for the management of PPP based on available evidence.

RESULTS

Pharmacological therapy is the mainstay of PPP management in the acute phase. Evidence points to a combination of antipsychotics and lithium in the acute treatment of PPP. Electroconvulsive therapy can offer a rapid treatment response where required. Lithium appears to have the best evidence for relapse prevention and prophylaxis in PPP. Psychoeducation is essential and psychosocial interventions used in bipolar disorder may be effective in PPP.

CONCLUSION

Early detection and prompt treatment with antipsychotics and lithium, followed by maintenance treatment with lithium, is associated with a favourable prognosis in PPP.

Postpartum Psychosis

PURPOSE OF REVIEW

Postpartum psychosis is a psychiatric emergency that can affect the health and life of mothers, infants, and families. Postpartum psychosis (PPP) is distinct from non-postpartum psychosis in many ways, and it is crucial to study and understand PPP to identify, treat, and possibly prevent this condition. We therefore sought to review the latest research findings about PPP with the intention of updating readers about the latest evidence base.

RECENT FINDINGS

Multiple physiologic pathways have been implicated in the development of PPP, and further understanding these pathways may allow for early detection and treatment. Risk assessment and treatment should include consideration of the woman patient but also the mother-infant dyad and the larger family. It is our hope that this review of research updates in postpartum psychosis may inform clinical practice and promote specialized, evidence-based diagnosis, risk assessment, and treatment.

Efficacy and Safety of Transcranial Electric Stimulation during the Perinatal Period: A Systematic Literature Review and Three Case Reports

Introduction: The perinatal period is an at-risk period for the emergence or decompensation of psychiatric disorders. Transcranial electrical stimulation (tES) is an effective and safe treatment for many psychiatric disorders. Given the reluctance to use pharmacological treatments during pregnancy or breastfeeding, tES may be an interesting treatment to consider. Our study aims to evaluate the efficacy and safety of tES in the perinatal period through a systematic literature review followed by three original case reports. Method: Following PRISMA guidelines, a systematic review of MEDLINE and ScienceDirect was undertaken to identify studies on tES on women during the perinatal period. The initial research was conducted until 31 December 2021 and search terms included: tDCS, transcranial direct current stimulation, tACS, transcranial alternating current stimulation, tRNS, transcranial random noise stimulation, pregnancy, perinatal, postnatal, and postpartum. Results: Seven studies reporting on 33 women during the perinatal period met the eligibility criteria. No serious adverse effects for the mother or child were reported. Data were limited to the use of tES during pregnancy in patients with schizophrenia or unipolar depression. In addition, we reported three original case reports illustrating the efficacy and safety of tDCS: in a pregnant woman with bipolar depression, in a pregnant woman with post-traumatic stress disorder (sham tDCS), and in a breastfeeding woman with postpartum depression. Conclusions: The results are encouraging, making tES a potentially safe and effective treatment in the perinatal period. Larger studies are needed to confirm these initial results, and any adverse effects on the mother or child should be reported. In addition, research perspectives on the medico-economic benefits of tES, and its realization at home, are to be investigated in the future.

Effects of Cognitive Nursing Combined with Continuous Nursing on Postpartum Mental State and Rehabilitation

Purpose

This study is aimed at exploring the effects of cognitive nursing combined with continuous nursing on postpartum mental state and rehabilitation.

Methods

Totally, 124 puerperas admitted to our hospital from January 2019 to January 2020 were selected and divided into a research group and a control group according to different nursing methods, with 62 cases in each group. The control group received routine care, while the research group received cognitive nursing combined with continuous nursing on this basis. The mental state, rehabilitation indicators, quality of life, incidence of complications, and nursing satisfaction were compared between the two groups after intervention.

Results

Before nursing, there was no statistically significant difference in the SAS and SDS scores between the two groups (P > 0.05); after intervention, the SAS and SDS scores of the two groups were significantly reduced, and those of the research group were lower than those of the control group (P < 0.05). After intervention, the time of the first breastfeeding, duration of lochia rubra, length of hospital stay, and score of uterine contraction pain of the research group were lower than those of the control group (P < 0.05); the psychological function, physical function, material life, and social function scores of the research group were higher than those of the control group (P < 0.05); the incidence of complications in the research group was 4.84%, lower than 20.97% in the control group (P < 0.05); the nursing satisfaction of the research group was 96.77%, which was significantly higher than 83.87% in the control group (P < 0.05).

Conclusions

Cognitive nursing combined with continuous nursing can effectively improve the mental state, shorten the length of hospital stay, increase the perceived well-being, and promote the physical rehabilitation in puerperas, which is worth promoting in clinical practice.

A Systematic Review of Neuromodulation Treatment Effects on Suicidality

Introduction: Neuromodulation is an important group of therapeutic modalities for neuropsychiatric disorders. Prior studies have focused on efficacy and adverse events associated with neuromodulation. Less is known regarding the influence of neuromodulation treatments on suicidality. This systematic review sought to examine the effects of various neuromodulation techniques on suicidality. Methods: A systematic review of the literature from 1940 to 2020 following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline was conducted. Any reported suicide-related outcome, including suicidal ideation, suicide intent, suicide attempt, completed suicide in reports were considered as a putative measure of treatment effect on suicidality. Results: The review identified 129 relevant studies. An exploratory analysis of a randomized controlled trial comparing the effects of sertraline and transcranial direct-current stimulation (tDCS) for treating depression reported a decrease in suicidal ideation favoring tDCS vs. placebo and tDCS combined with sertraline vs. placebo. Several studies reported an association between repetitive transcranial magnetic stimulation and improvements in suicidal ideation. In 12 of the studies, suicidality was the primary outcome, ten of which showed a significant improvement in suicidal ideation. Electroconvulsive therapy (ECT) and magnetic seizure therapy was also shown to be associated with lower suicidal ideation and completed suicide rates. There were 11 studies which suicidality was the primary outcome and seven of these showed an improvement in suicidal ideation or suicide intent and fewer suicide attempts or completed suicides in patients treated with ECT. There was limited literature focused on the potential protective effect of vagal nerve stimulation with respect to suicidal ideation. Data were mixed regarding the potential effects of deep brain stimulation on suicidality. Conclusions: Future prospective studies of neuromodulation that focus on the primary outcome of suicidality are urgently needed. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=125599, identifier: CRD42019125599.

Recent Updates on Electro-Convulsive Therapy in Patients with Depression

OBJECTIVE

Electro-convulsive therapy (ECT) has been established as a treatment modality for patients with treatment-resistant depression and with some specific subtypes of depression. This narrative review intends to provide psychiatrists with the latest findings on the use of ECT in depression, devided into total eight sub-topics.

METHODS

We searched PubMed for English-language articles using combined keywords and tried to analyze journals published from 1995-2020.

RESULTS

Pharmacotherapy such as antidepressants or maintenance ECT is more effective than a placebo as prevention of recurrence after ECT. The use of ECT in treatment-resistant depression, depressed patients with suicidal risks, elderly depression, bipolar depression, psychotic depression, and depression during pregnancy or postpartum have therapeutic benefits. As possible mechanisms of ECT, the role of neurotransmitters such as serotonin, dopamine, gamma-aminobutyric acid (GABA), and other findings in the field of neurophysiology, neuro-immunology, and neurogenesis are also supported.

CONCLUSION

ECT is evolving toward reducing cognitive side effects and maximizing therapeutic effects. If robust evidence for ECT through randomized controlled studies are more established and the mechanism of ECT gets further clarified, the scope of its use in the treatment of depression will be more expanded in the future.

Managing bipolar disorder during pregnancy and the postpartum period: a critical review of current practice

Introduction: Despite increased interest in the pharmacotherapy of bipolar disorder during pregnancy and the postpartum period, management of the disorder during these critical periods in a woman's life remains challenging.Areas covered: The authors review the effect of pregnancy and the postpartum period on the course of bipolar disorder, describe adverse pregnancy and birth outcomes, and discuss the pharmacotherapy of bipolar disorder during and after pregnancy.Expert opinion: When treating women with bipolar disorder of childbearing age, clinicians should consider the possibility of pregnancy. Pre-conception counseling should be an integral part of the overall plan to manage bipolar disorder during and after pregnancy. Peripartum management of bipolar disorder is challenging and requires balancing of risks associated with the use of drugs and the potentially deleterious effects of untreated bipolar disorder on the fetus/child. Formulation of personalized treatment requires knowledge of both current (episode type, symptom severity, psychiatric comorbidity, and safety concerns) and historical (episode frequency, response to drugs and psychotherapy, and the effect of reproductive events including pregnancy and postpartum period) factors. Close monitoring is essential for early detection and management of mood episodes. Routine safety assessments are necessary to identify women at risk of harming themselves or the newborn.