We appreciate Dr. Pinette’s letter and acknowledge that there is much uncertainty in the treatment of pregnant women with psychiatric conditions. However, we would like to clarify the statements in our article. First, the case reports compiled by Dr. Miller in her review of electroconvulsive therapy (ECT)1 and Dr. Pinette’s case report2 do not adequately consider the severity of the underlying psychiatric illness or previous failed pharmacotherapy trials as the indications for ECT. The resulting risk to women who receive ECT is likely confounded by indication. Many women who were included in case reports1,2 suffered from bipolar disorder rather than unipolar depression. Bipolar disorder is characterized by deficient sleep, marked increase or decrease in energy, decreased appetite, poor self-care, inappropriate and bizarre behavior, and, often, hazardous substance use. Individuals with bipolar disorder as well as severe unipolar depression frequently experience at least one, if not many, trials of psychotropic medications. Among the medications used to treat bipolar disorder and refractory depression are drugs that are known teratogens (valproic acid, carbamazepine, and lithium). Moreover, reporting bias occurs with single case reports involving negative outcomes for which no denominator is known for establishment of a risk estimate. In light of this, the causality implied by Dr. Pinette’s case report is not a balanced interpretation of the existing literature. Even the comprehensive early review conducted by Dr. Miller1 might be considered biased toward negative events.
It is true that we lack high-quality data on the risks of ECT compared with no ECT for pregnant women who suffer from severe unipolar depression.3 In our report, we state that ECT is a treatment option for depressed pregnant women, “especially when the depressive disorder is life threatening or fails to respond to antidepressant drugs.”4 We agree that this option should be approached carefully, and nearly all clinicians and experts would recommend its use to a subgroup of women with severe illness who have not responded to other treatments. However, given its efficacy and the lack of evidence that it confers harm to the developing fetus beyond the risk of psychiatric illness or other treatments, pregnant women should not be excluded from this option.
Financial Disclosure:
Dr. Yonkers received medications from Pfizer (New York, NY) to conduct a National Institute on Mental Health ([NIMH] Bethesda, MD) study and funding from Eli Lilly Co. [Indianapolis, IN])to conduct an investigator-initiated trial. She has received author royalties from UptoDate (http://www.uptodate.com) and has received study support from the National Institute on Drug Abuse, the NIMH, and the National Institute of Child Health and Human Development ([NICHD] Bethesda, MD). Dr. Wisner serves on the advisory board at Eli Lilly Co. and has received a donation of active and placebo transdermal estradiol patches for an NIMH funded study from Novartis (Basel, Switzerland). She has also served on the speakers bureau for GlaxoSmithKline (Philadelphia, PA), and has received a research grant from Pfizer. The other author did not report any potential conflicts of interest.
Contributor Information
Kimberly A. Yonkers, Departments of Psychiatry and Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut.
Charles J. Lockwood, Department of Obstetrics, Gynecology and Reproductive Sciences, Yale School of Medicine, New Haven, Connecticut.
Katherine Wisner, Departments of Psychiatry, Obstetrics and Gynecology and Reproductive Sciences, Epidemiology, and Women’s Studies, Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
REFERENCES
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