Modified electroconvulsive therapy for perinatal depression: scoping review

Modified electroconvulsive therapy (mECT), the administration of ECT under general anesthesia with muscular relaxation, is indicated for perinatal depression complicated by high severity, psychosis, catatonia, or resistance to conventional therapeutics; however, knowledge gaps remain regarding its effectiveness and safety in depressed patients and its fetal/neonatal risk profile.

We conducted a scoping review of the literature describing the effectiveness and safety (maternal, fetal, and neonatal) of mECT for perinatal depression. Online databases were searched (inception to December 31, 2024) to identify clinical trials, observational studies, case series, and case reports that were topically relevant. Information on key methodological details, clinical characteristics, interventions, and outcomes from each report was extracted by all investigators working in pairs, using an electronic abstraction form.

A total of 82 reports (with information on >1,300 pregnancies/deliveries) were included, consisting mainly of case reports (n=57) and case series (n=14), with the remaining citations being non-randomized or retrospective studies. The reviewed reports collectively described a broad spectrum of effectiveness and safety outcomes associated with predominantly acute mECT across multiple forms of perinatal depression, multiple trimesters of pregnancy, and the postpartum. mECT conferred rapid benefit for depressive, psychotic, and catatonic symptoms in severely depressed perinatal patients when effectiveness outcomes were described. The most frequent adverse events were generally mild and transient. However, cases of placental abruption (n=1), premature delivery (n=21), congenital malformations (n=6), and stillbirth (n=4) were also reported across the reviewed reports. Due to limited information, causal links between mECT and many adverse events were difficult to establish and inferences about differential effectiveness and safety between important patient subgroups or variations in mECT technique could not be drawn.

mECT appears to be an effective acute phase treatment for severely ill perinatally depressed patients. Although the maternal safety profile of mECT appears reassuring, the available data are far from comprehensive. Moreover, fetal and neonatal safety risks are even less-well-characterized. mECT should be regarded as an important therapeutic option for severe cases of perinatal depression. Informed consent practices should reflect the knowledge gaps highlighted in this review in addition to the well-known side-effects of mECT and the substantial adverse consequences of untreated or undertreated maternal depression.

This project was registered on Open Science Forum, 10.17605/OSF.IO/KB67J.