Electroconvulsive therapy in treatment-resistant depression

What is the role of electroconvulsive therapy (ECT) in the treatment of mood disorders, especially treatment-resistant depression (TRD)? While many have thought that ECT has been replaced by pharmacotherapy, ECT is still frequently used, with the number of treatments conducted annually in the United States exceeding coronary bypass, appendectomy, tonsillectomy, and hernia repair. Controlled studies and clinical experience indicate that the short-term efficacy of ECT in major depression is comparable, and likely superior, to that of any other antidepressant treatment. Patients with TRD consume a disproportionate share of medical resources and this condition often presents extraordinary burdens to the individual, family, and society. Relative to any other antidepressant treatments, ECT has the highest rate of response/remission, the fastest onset of symptom relief, and the most complete symptom relief. However, ECT has two major drawbacks that limit its use: its effects on memory and high rate of relapse. Current research is directed at improving cognitive outcomes and identifying more effective prophylactic treatment following ECT. Novel innovations include methods to produce seizures with focal onset and limited propagation. Such modifications have the potential to markedly reduce the adverse effects of ECT without compromising efficacy.