Introduction 

Electroconvulsive therapy is a treatment option for severe depression that has been resistant to other forms of treatment, or an episode that is so severe that life is at risk or symptoms require immediate resolution. Severe depression can manifest after giving birth (i.e. in the postpartum period) and electroconvulsive therapy can be carried out in this period too. Given the nature of electroconvulsive therapy, it is reserved for select severe cases. This article aims to give an overview of electroconvulsive therapy for postpartum depression. 

Overview of postpartum depression

The postpartum period- which can be any time up to 12 months after giving birth- is a critical period for the mental health of the mother. Severe psychiatric illness can develop, including severe depression. This can be either a new onset depression or a relapse of previously diagnosed (i.e. before becoming pregnant) depression.² It is important to distinguish postpartum depression (PPD) from “baby blues”. Baby blues are commonly felt feelings of sadness after giving birth, which are usually self-limiting³ after the baby is around 10 days old.⁹ Baby blues can affect around half of all women who have a baby.⁹

PPD is diagnosed as a persistent feeling (meaning over 2 weeks) of low mood, apathy, changes in sleeping and appetite. Suicidal thoughts (and/or actions) can also be experienced.⁴ The symptoms mentioned above can also not be attributed to any other medical condition to be diagnosed as PPD.⁴ PPD is also referred to as perinatal depression - the latter term recognising that symptoms can present during pregnancy as well as after birth.¹¹ PPD affects around 10-15% of women who have a baby.⁹ Suicidal thoughts are usually not present in “baby blues”.⁴ 

PPD can have a significant impact on the new mother, the baby and the rest of the family around them. The mother is often the main carer of the newborn so it is important that she is in a healthy state to do so. It can affect bonding between the newborn and the mother and child¹¹ and in some extreme cases, mothers have reported having thoughts of harming their baby.⁴ Therefore, PPD must not be left untreated. 

Electroconvulsive therapy for postpartum depression

Electroconvulsive therapy (ECT) is a treatment used to treat severe psychiatric illnesses including severe depression. ECT is carried out under general anaesthesia where the patient receives a series of electrical impulses, usually lasting between 0.5 and 2.0 milliseconds (known as ‘brief pulse’ ECT) which induce seizures (aka fits or convulsions). There is another form of ECT called ‘ultra-brief’ ECT where impulses last less than 0.5 milliseconds.

A muscle-relaxing drug is also given to limit movements during seizures. Electrodes (metal discs) are placed on the head to transmit the electrical impulses. These can either be bilateral (one electrode placed on either side of the head) or unilateral (both electrodes on one side).⁵ Treatment is usually carried out 2-3 times per week for a few weeks. ECT is generally regarded as a treatment option for severe cases that have not responded to medication (and if applicable, psychological therapies), or in severe cases where immediate symptom management is necessary.¹ 

If the patient is at risk to life, or there is another reason why it is an emergency and the patient cannot consent for themselves, treatment will be carried out by the health professionals in the best interests of the patient. If it is not an emergency, the patient will be given all the necessary information before starting ECT to be able to make an informed decision and be able to discuss it with the family.⁵

As with any medical treatment, there are risks associated with ECT. Some are short-term after the procedure such as nausea and vomiting. Memory deficits have also been reported, most resolving within two months, although some patients have found have found persisted for longer.⁶ Overall though, ECT remains a perfectly valid treatment option, with many patients having marked improvements because of it.^1,2,4 According to the 2014 NICE guidelines in the UK, ECT should be considered only in select cases where the physical health of the mother or the health of the foetus is at ‘significant risk’.⁸ ECT has the best results during the postpartum period rather than after.⁷

Barriers to ECT can include logistical issues like hospital stays, childcare and having someone to look after the mother after having had ECT. The stigma around ECT (and even PPD) is another very real problem that new mothers face, and therefore (either knowing that they may have PPD or not) do not seek treatment.³ The stigma of ECT has partly stemmed from the way that it used to be conducted- without anaesthesia. This resulted in significant memory deficits and harm to the patients.¹ The negative portrayal of ECT in media and popular culture contributes to the stigma too.¹¹ However, with general anaesthetic, in a controlled environment with trained professionals (i.e. anaesthetists, psychiatrists, nurses etc), ECT is safe to carry out.^2,4

Results of electroconvulsive therapy in postpartum depression

Evidence has shown that ECT can be a highly effective means of treating severe PPD. Patients overall reported that the benefits far outweighed the minor short-term memory deficits.^1,2,7 Some patients found it so helpful that they went on to make advanced decisions: should they relapse severely again,  they would want ECT to be given, in the event that they are unable to consent for themselves at the time.⁵  

Alternatives to electroconvulsive therapy

ECT is not the only treatment modality that is available for postpartum depression.

Psychotherapy is another option (like CBT, mindfulness-based interventions, or group therapy (like in a support group) which is completely non-invasive and can be a popular choice. Lifestyle modifications like exercising, and a healthy diet can also help with mood.⁷

Medication is a well-known treatment option for depression as well. This article will not go into advice on medication. A point of caution: any decision regarding starting, stopping or changing antidepressants (or any psychiatric medication) during pregnancy, breastfeeding or during pregnancy the postpartum period should be taken after speaking with doctors- a GP with advice from a specialist perinatal team or from a psychiatric team.¹⁰

However in very severe cases (especially if other treatment has been tried unsuccessfully), where the safety of the mother may be compromised (i.e the mother is actively suicidal), or if the mother is too unwell to take care of herself and/or the baby, the immediate need for safety and stability needs to be weighed up against the risks of treatment.⁵ 

Depression as part of other psychiatric illnesses

Depression, or symptoms of depression can present as part of other psychiatric conditions. These can present during the postpartum period, but those with the following conditions should be distinguished from those with postpartum depression. 

Depression is a component of bipolar disorder. Some women who were diagnosed with bipolar disorder prior to becoming pregnant relapsed after giving birth. Depression can also be a component of schizophrenia, or schizoaffective disorder (schizoaffective disorder is a diagnosis of schizophrenia plus a mood disorder like depression or bipolar disorder). In one study, ECT was found to be effective in these patients as well when symptoms were severe.²

Postpartum psychosis is a psychiatric emergency and is when people “lose touch” with reality. It can involve hallucinations (seeing, hearing, smelling or feeling things that are not actually there) and delusions (fixed false beliefs despite evidence to contradict). Erratic and rapid mood changes can also be seen. Symptoms of depression and low mood can also occur, but if there is a case of postpartum psychosis, there will be other symptoms too.⁹ ECT can be used in postpartum psychosis where immediate intervention is necessary.⁸

Summary

ECT is a safe and effective method for treating PPD² but is to be used with caution in select cases. Those that have severe depressive symptoms- like being actively suicidal- have been shown to respond very well to ECT.⁷ When left untreated, PPD can have a severe impact on the mother, baby and those around them. It is important that PPD is treated, whichever mode of treatment may be chosen. The choice will be considered on an individual basis as per the needs of the patient and family.