Use of Electroshock Therapy vs. Antidepressants for Postpartum Psychosis
Literature on postpartum psychiatric diagnosis leans heavily toward trying to understand postpartum depression, but talks little of postpartum psychosis. The reason for this seems to be that the depression diagnosis is much more prevalent than psychosis. However, there have been enough reports of postpartum psychosis that it has become more of a known diagnosis. Most coverage of psychosis has been in media reports which show the extreme acts of a mother who is having a psychotic break after giving birth. One such case is that of Andrea Yates, a Texas mother who drowned her young children.
Yates, the mother of five children aged seven years to six months, drowned all five of the children in June of 2001. She had been previously diagnosed with postpartum depression and psychosis, and her husband was advised not to leave the children alone with her. Two weeks prior to the drowning deaths, her husband began leaving the children with her for an hour every afternoon. The courts originally convicted her of the deaths and sentenced her to life in prison, but that decision was reversed on appeal. Yates was sentenced to spend time at a maximum security mental facility, which was lately reduced to minimum security.
To ensure that the reader understands the intricacies of the primary terms used in this research paper, definitions of some words and phrases are necessary. Although a definition of postpartum psychosis has been difficult to accurately determine "It appears that in most cases, postpartum psychosis represents an episode of bipolar illness; the symptoms of puerperal psychosis most closely resemble those of a rapidly evolving manic (or mixed) episode" (MGH Center for Women's Mental Health, 2008). The treatment of the condition will be discussed in a later section, but the treatments themselves need to be defined also. Antidepressants come in several forms (tri-cyclics, MAOIs, SSRIs and SNRIs), but they all act to defeat depressive symptoms by "inhibiting neurotransmitter breakdown as a primary mechanism of action" (Keltner, 2002). Electroshock therapy is another possible treatment which has been used since the early part of the last century, but the practice has gotten much better over time. Clinically called electroconvulsive therapy (ECT), the practice "involves the induction of a grand mal seizure, or convulsion, by passing electricity through the brain" (Frank, 2006). The efficacy of this treatment type will be discussed later. Another possible treatment for postpartum psychosis is to use a combination of the two therapies.
Of the two primary treatments, ECT or antidepressants, antidepressants are most often used because the process is thought to be safer than the alternative. However, this is primarily when the diagnosis is postpartum depression. Since there is no longer any danger to the baby of being dosed along with the mother (unless the mother is breast feeding), many mothers who experience the effects of postpartum depression are provided a regimen of antidepressants. However, this can be problematic since the side effects of some antidepressants can be severe. MAOIs and tri-cyclics are rarely, if ever, administered today, but the miracle SSRIs are very common. However, even they have some side effects such as possible insomnia, gastrointestinal distress and sexual dysfunction (Keltner, 2002). However, research has proven that antidepressants are somewhat effective in the treatment of postpartum psychosis (Elin, 2011), but the effects are transitory and small.
Electroconvulsive therapy is one type of treatment that has been controversial almost since it was first used. Inducing a general seizure when research has proven that such an action can cause multiple levels of permanent damage (Breggin, 2007), does not seem to be a good idea. However, the practice has proven effective when used to treat depression and postpartum psychosis (Engqvist, et al., 2011). The primary side effect is partial permanent memory loss which can digress toward symptoms of other mental illness (Breggin, 2007). The fact that the treatment may cause this type of damage has caused it to be used sparingly. It is only indicated when the depression is very severe and does not respond to other types of treatment, or when it shows efficacy for other disorders such as postpartum psychosis (Fran, 2006). However, some have called ECT the "penicillin of psychiatry" (Kragh, 2010) because it was once used to a great extent. Because of the issues which have been brought to light during research into its effectiveness vs. damage done, ECT is not as pervasive as it once was.
The preferred choice of therapies is to use antidepressants in conjunction with antidepressants to treat depression and more severe complaints such as postpartum psychosis (Science Daily, 2009). The most glaring problem with using ECT as a treatment for any disorder is that it causes memory loss. A recent study by the Wake Forest School of medicine found that ECT, when used in conjunction with antidepressants, is a much more desirable treatment regimen. The head researcher stated "This finding could alleviate one of the primary concerns about ECT -- that it causes memory loss" (Science Daily, 2009). ECT alone has just a 70% to 80% response rate, but most of those patients still suffer some memory loss (Science Daily, 2009). The research found that the optimum treatment was to use unilateral ECT (on one hemisphere of the brain only) in conjunction with an SSRI antidepressant (Effexor was more effective than an MAOI which was also included in the study). Because of this efficacy with depression the combination has been studied with women diagnosed with postpartum psychosis also.
Because any psychosis presents differently than even severe depression, the same treatments are not often indicated. However, doctors in Sweden conducted a study in which the effectiveness of combined therapy was attempted. Previously, doctors had found that ECT was very effective for mothers with postpartum depression, and it was the treatment of choice "especially for mothers who were breastfeeding" (Engqvist, et al., 2011). However, because the psychosis was considered a danger to the child, breast feeding was usually not an issue. Mothers were first treated using ECT in conjunction with an antipsychotic, then, because "women with PPP [postpartum psychosis] show mixed symptoms of mood and anxiety disorders" (Engqvist, et al., 2011). This combination was shown to be the most effective, however the study was not quantitative in nature which may bring its results into question. The limitation is that self-report was the method of data gathering which is a less effective way of gathering data than a quantitative study.
Support of ECT
Many people continue to support the use of ECT, especially medical personnel, because they have seen how effective it is as a treatment for severe psychiatric illness. There have been many instances when a patient faced a life fraught with psychosis or severe depression and it has either been mitigated or eliminated when ECT was used. These findings have been frequent enough that ECT has continued to be a cause celebre among some psychiatric staffs.
Opposition to ECT
Unfortunately, for those who support the use of ECT by itself, there are many more studies which prove that the practice is, at best, temporary. Patients who undergo an ECT treatment most often are tasked with having bi-yearly maintenance doses administered (Frank, 2006). This means that the patient cannot have just one ECT treatment. Professionals who oppose the use of ECT as a therapy have many arguments against it continued use. Many point to the beginnings of the treatment and the myths that were promulgated as a result of overanxious doctors (Kragh, 2010). Beside the perpetuation of myths, there have been studies which promoted the placebo effect as a reason for the supposed recovery or the strong belief system of the patient. There has even been legislation enacted in some states to stop the practice altogether (Frank, 2006).
The most logical treatment for postpartum psychosis would be the one that has proven to be the most effective. However, due to the limited research conducted on the issue that is difficult to determine. The best way to see what will work is to use the few studies which suggest an effective treatment, and infer from others.
Severe depression presents itself similarly to postpartum psychosis, so treatments that have been effective controls for severe depression would appear effective for postpartum psychosis also (Gagne, et al., 2000). Authors of several studies have noted the effectiveness of the combination treatment in alleviating psychotic symptoms which show themselves in patients who are diagnosed with severe depression (Gagne, et al., 2000). However, this combination may also be positively affected by the addition of counseling which has proven its efficacy in different research studies (Hagen, Wong-Wylie, Pijl-Zeiber, 2010). It is best to conduct more studies into the efficacy of all of these treatments because of the few that have been conducted in the past.
Because of the severe nature of the condition, it would seem that more research would have been conducted. However, since the diagnosis is rare, the…
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