A comparison of clinical response to electroconvulsive therapy in puerperal and non-puerperal psychoses.

BACKGROUND: There is a widespread belief that puerperal psychosis is particularly responsive to electroconvulsive therapy (ECT), but research evidence for this is lacking. METHOD: We have conducted a retrospective case-note study of clinical improvement following ECT in puerperal and non-puerperal psychosis. The main outcome measure was improvement in mental state at the end of a course of ECT, rated by a blind rater on a simple four-point scale. Additional indicators of responsiveness to ECT were improvement in mental state 4 weeks after stopping ECT, duration of in-patient stay following ECT and number of ECT received. RESULTS: Women with puerperal psychosis showed greater clinical improvement than women with non-puerperal psychosis. The results were not explained by the greater preponderance of depressive illness in the puerperal group, as the same results were also found when the analysis was confined to women with a clinical diagnosis of depressive illness. CONCLUSION: These findings are the first evidence of a particular sensitivity of ECT in puerperal psychosis. However, they are preliminary and a number of explanations are possible, including good responsiveness to treatment in general. A prospective study using standardised clinical ratings and definitions of key variables is now required. CLINICAL IMPLICATIONS: Clinicians treating severe postpartum illness should continue to regard ECT as a treatment option. LIMITATIONS OF THE STUDY: The study is limited by its reliance on retrospective examination of information recorded in case notes. Ratings of clinical improvement were not standardised.

Systematic approach to community risk assessment and management.

A move from institutional to community health care means that health service staff are increasingly requested to visit patients in their own homes. This undertaking is not without risk, particularly where the patient or the locality is unknown. There are no nationally available guidelines for formally assessing potential risk to a health worker before the home visit. A protocol for risk assessment and a safety schedule before making a home visit was therefore developed and is described in this article. The difficulties in carrying out a comprehensive risk assessment are outlined. Several ways in which the assessment of risk before home visits could be made more effective are suggested.