OBJECTIVE: To inform obstetricians and psychiatrists about the safety of electroconvulsive therapy (ECT) administration during pregnancy and to reconcile conflicting recommendations concerning this treatment.
METHODS: A systematically conducted overview was undertaken on the safety of ECT during pregnancy. The Cochrane Library, MEDLINE/PubMed, PsycINFO, and Ovid were independently searched by 2 of the authors from January 2015 to March 2017 using the following search terms: electroconvulsive therapy, ECT, and electroshock combined with pregnancy and reviews. Articles were reviewed and critically appraised using components of the PRISMA and AMSTAR systematic review assessment tools.
RESULTS: Of the 9 articles that were identified, 5 publications of varying methodological quality met inclusion criteria and involved a range of 32 to 339 patients. The most common problems that occurred in association with ECT were fetal arrhythmia, fetal bradycardia, premature birth, developmental delay, abdominal pain, uterine contraction, vaginal bleeding, placental abruption, and threatened abortion. The number of fetal deaths in each of the reviews ranged from 2 to 12. The authors of 1 of the 5 reviews recommended that ECT only be used as a last resort, whereas the authors of the other reviews took the stance that the administration of ECT during pregnancy was relatively safe. Differences in recommendations among reviews were in part due to inclusion criteria and how adverse events were attributed to ECT.
CONCLUSIONS: Our overview supports the conclusion, which has also been endorsed by the American College of Obstetricians and Gynecologists and the American Psychiatric Association, that administration of ECT during pregnancy is relatively safe. Conclusions about safety, however, will become better established with the availability of more data.
BACKGROUND: Four systematic reviews have examined the safety of electroconvulsive therapy (ECT) in pregnancy. These have varied widely in methods, findings, and conclusions.
METHODS: We compared these reviews with regard to search strategy, study selection criteria, total number of studies identified, total number of patients included, findings related to safety and adverse events, and interpretation of results.
RESULTS: The number of studies (number of cases) included in the reviews ranged from 16 (n = 300) to 67 (n = 169) with only one review stating reasons for exclusion of nonselected studies. We provide comparisons about how the reviews described patient characteristics, illness characteristics, ECT characteristics, confounder characteristics, and outcome characteristics; there was wide variation in these regards. We list adverse outcomes that were identified by some but not other reviews. We provide a detailed breakdown of the adverse maternal and fetal outcomes identified in each review. Finally, we examine how different reviews interpreted their findings; whereas some reviews provided reasons for ruling out ECT as an explanation for an adverse outcome, one review adopted the stance that all adverse outcomes were potentially ECT-related.
CONCLUSIONS: Our meta-review provides readers with comparative information on the strengths and limitations of the 4 systematic reviews, their findings, and their conclusions. It can assist with clinical decision making on the use of ECT in pregnancy by providing a more complete description of the available literature.
To establish the clinical effectiveness and cost-effectiveness of electroconvulsive therapy (ECT) for depressive illness, schizophrenia, catatonia and mania. Electronic bibliographic databases. The reference lists of relevant articles and health services research-related resources were consulted via the Internet. Identified studies were examined to ascertain whether they met the inclusion criteria for the review. The study quality of relevant articles was assessed using standard checklists and data were abstracted using standardised forms into a database. Where relevant, results from studies were pooled for meta-analysis. Two economic models were developed primarily based on evidence from the clinical effectiveness analysis and limited quality of life studies. Two good-quality systematic reviews of randomised evidence of the efficacy and safety of ECT in people with depression, schizophrenia, catatonia and mania were identified. Four systematic reviews on non-randomised evidence were also identified, although only one of these could be described as good quality. There was no randomised evidence of the effectiveness of ECT in specific subgroups including older people, children and adolescents, people with catatonia and women with postpartum exacerbations of depression or schizophrenia. The economic modelling results for depression did not demonstrate that any of the scenarios had a clear economic benefit over the others, mainly because of the uncertainty surrounding the clinical effectiveness of the different treatments and the quality of life utility gains. Sensitivity analysis surrounding the cost of ECT and the quality of life utility values had little effect on the overall results. The results of the model for schizophrenia adapted to include ECT suggest that clozapine is a cost-effective treatment compared with ECT. For patients who fail to respond to clozapine, ECT treatment may be preferred to the comparative treatment of haloperidol/chlorpromazine. Real ECT is probably more effective than sham ECT, but as stimulus parameters have an important influence on efficacy, low-dose unilateral ECT is no more effective than sham ECT. ECT is probably more effective than pharmacotherapy in the short term and limited evidence suggests that ECT is more effective than repetitive transcranial magnetic stimulation. Tricyclic antidepressants (TCAs) may improve the antidepressant effect of ECT during the course of treatment. Continuation pharmacotherapy with TCAs combined with lithium in people who have responded to ECT reduces the rate of relapses. Overall, gains in the efficacy of the intervention depending on the stimulus parameters of ECT are achieved only at the expense of an increased risk of cognitive side-effects. Limited evidence suggests these effects do not last beyond 6 months, but there is no evidence examining the longer term cognitive effects of ECT. There is little evidence of the long-term efficacy of ECT. ECT either combined with antipsychotic medication or as a monotherapy is not more effective than antipsychotic medication in people with schizophrenia. More research is needed to examine the long-term efficacy of ECT and the effectiveness of post-ECT pharmacotherapy, the short-term and longer term cognitive side-effects of ECT, and the impact of ECT on suicide and all-cause mortality. Further work is needed to examine the information needs of people deciding whether to accept ECT and how their decision-making can be facilitated. More research is also needed on the mechanism of action of ECT. Finally, the quality of reporting of trials in this area would be vastly improved by strict adherence to the Consolidated Standards of Reporting Trials recommendations. Economic analysis may identify areas in which research would be best targeted by identifying parameters where reducing the level of uncertainty would have the most effect in helping to make the decision on whether ECT is a cost-effective treatment.
Clinical and cost-effectiveness of electroconvulsive therapy for depressive illness, schizophrenia, catatonia and mania: Systematic reviews and economic modeling studies (PDF Download Available). Available from: https://www.researchgate.net/publication/7961151_Clinical_and_cost-effectiveness_of_electroconvulsive_therapy_for_depressive_illness_schizophrenia_catatonia_and_mania_Systematic_reviews_and_economic_modeling_studies [accessed Dec 09 2017].
To inform obstetricians and psychiatrists about the safety of electroconvulsive therapy (ECT) administration during pregnancy and to reconcile conflicting recommendations concerning this treatment.
METHODS:
A systematically conducted overview was undertaken on the safety of ECT during pregnancy. The Cochrane Library, MEDLINE/PubMed, PsycINFO, and Ovid were independently searched by 2 of the authors from January 2015 to March 2017 using the following search terms: electroconvulsive therapy, ECT, and electroshock combined with pregnancy and reviews. Articles were reviewed and critically appraised using components of the PRISMA and AMSTAR systematic review assessment tools.
RESULTS:
Of the 9 articles that were identified, 5 publications of varying methodological quality met inclusion criteria and involved a range of 32 to 339 patients. The most common problems that occurred in association with ECT were fetal arrhythmia, fetal bradycardia, premature birth, developmental delay, abdominal pain, uterine contraction, vaginal bleeding, placental abruption, and threatened abortion. The number of fetal deaths in each of the reviews ranged from 2 to 12. The authors of 1 of the 5 reviews recommended that ECT only be used as a last resort, whereas the authors of the other reviews took the stance that the administration of ECT during pregnancy was relatively safe. Differences in recommendations among reviews were in part due to inclusion criteria and how adverse events were attributed to ECT.
CONCLUSIONS:
Our overview supports the conclusion, which has also been endorsed by the American College of Obstetricians and Gynecologists and the American Psychiatric Association, that administration of ECT during pregnancy is relatively safe. Conclusions about safety, however, will become better established with the availability of more data.
