Depression remains the most frequent disorder for which ECT is required. This chapter summarises the evidence for the efficacy of ECT in depression and practical guidelines for its use. The Department of Health commissioned a systematic review of the safety and efficacy of ECT in depression (UK ECT Review Group, 2003), and for the NICE guidance on depression in adults, a further systematic review was undertaken (National Collaborating Centre for Mental Health, 2010: pp. 509–528.)

Efficacy of ECT in depression

The UK ECT Review Group (2003) examined data from randomised controlled trials identified in an extensive search. The results were independently checked by two reviewers. Data from studies which met inclusion criteria were extracted by paired members of the review team. Identified trials were assessed for methodology, where appropriate and data from individual trials were summarised by meta-analyses.

ECT v. ‘sham’ ECT

Six randomised controlled trials comparing ECT with ‘sham’ ECT in the short-term treatment of depression were examined by the UK ECT Review Group (2003). They included data on a total of 256 patients (Wilson et al, 1963; Lambourn & Gill, 1978; Freeman et al, 1978; Johnstone et al, 1980; West, 1981; Gregory et al, 1985). Most participants were in-patients under the age of 70 with some form of depressive disorder. The depression ratings at the end of treatment showed the standardised effect size (SES) between real and simulated ECT to be –0.91 (95% CI –1.27 to –0.54), indicating a mean difference in the Hamilton Rating Scale for Depression (HRSD) of 9.67 (95% CI 5.72 to 13.53) in favour of ECT. There have been no trials comparing ECT with sham ECT since the last edition of the Handbook.

ECT v. pharmacotherapy

In 18 randomised controlled trials with a total of 1144 patients, ECT was compared with antidepressant medication in the short-term treatment of depression. Of these, 13 trials contained sufficient data to contribute to a pooled analysis. The SES of these trials was –0.80 (95% CI –1.29 to –0.29). This equates to a mean difference of 5.2 (95% CI 1.37 to 8.87) on the HRSD in favour of ECT. None of these trials compared ECT with newer antidepressant medications such as SSRIs, mirtazepine or venlafaxine.