We agree that the superior efficacy and faster onset of action of ECT compared with other treatment modalities warrants the earlier application of ECT in the treatment of elderly patients suffering from severe depression. The growing evidence of superior efficacy in the subgroup of elderly patients ^{Reference Rhebergen, Huisman, Bouckaert, Kho, Kok and Sienaert1} suggests the existence of distinctive subgroups with individual, clinical, cognitive and genetic parameters predicting response or non-response, as well as the emergence of side-effects. An exploratory study on clinical and cognitive profiles that predict early and complete remission with a Clinical Global Impression of Severity of 1 within 2 weeks of treatment has been submitted for publication. Brief pulse treatment, older age, shorter duration of the current depressive episode and psychosis predicted fast remission, but also a lower executive function at baseline as measured with letter fluency (effect size d = 0.9, P = 0.071), compared with the late remitters.

Our group has just completed the Mood Disorders in Elderly treated with Convulsive Therapy (MODECT) study, which included 110 patients with a mean age of 73 years (range 55–90 years). This study aims to identify predictors for the efficacy of ECT using neuroimaging, clinical measures (on cognition, mood and psychomotor symptoms), neuropsychological data and biological measurements. Recently, another research group in The Netherlands presented exciting data using a functional magnetic resonance imaging marker for the prediction of individual ECT outcome. ^{Reference van Waarde, Scholte, van Oudheusden, Verwey, Denys and van Wingen2} The MODECT data provide a wonderful opportunity to study and possibly replicate these findings in an older cohort.

With respect to the optimal treatment modality, we agree that the speed of remission using ultra-brief pulse ECT in the PRIDE study was indeed comparable to the speed of remission of the merged ultra-brief/brief pulse ECT groups. ^{Reference Spaans, Sienaert, Bouckaert, van den Berg, Verwijk and Kho3} However, the assessments of week 2 of the ECT group were neglected for comparison with the medication group. In the original ECT study, ^{Reference Spaans, Verwijk, Comijs, Kok, Sienaert and Bouckaert4} this elderly, brief pulse subgroup achieved remission significantly faster than the elderly, ultra-brief pulse subgroup: remission was achieved in 2.2 weeks (s.d. = 0.9) v. 3.0 weeks (s.d. = 1.1; t(29) = –2.249, P = 0.032), respectively. This finding may denote the possibility that twice-weekly brief pulse ECT with either unilateral or bilateral electrode placement could have superior efficacy compared with ultra-brief pulse treatment.

The recent evidence shown by our research and the recent findings of the PRIDE study once more emphasise the clinical importance of ECT’s rapid effect; ECT should indeed be taken into account when revising treatment algorithms for severely depressed elderly patients, hence avoiding the use of the less effective and slower-acting antidepressant medication.