Each electrode placement is a very effective antidepressant treatment when given with appropriate electrical dosing. Bitemporal leads to more rapid symptom reduction and should be considered the preferred placement for urgent clinical situations. The cognitive profile of bifrontal is not substantially different from that of bitemporal.

Bilateral ECT is effective in relieving severe major depression. Remission rates are higher and occur earlier in psychotic depressed patients than in nonpsychotic depressed patients. These data support the argument that psychotic depression is a distinguishable nosological entity that warrants separate treatment algorithms.

Primary depression can be associated with substantial hypercortisolism, thus prompting some researchers to suggest that depression shares pathophysiologic features with Cushing's disease. Clinically, depression can be difficult or impossible to distinguish from mild or early Cushing's disease that is associated with depressive features. The purpose of this study was to evaluate whether the pituitary-adrenal responses to ovine corticotropin-releasing hormone could help to clarify the mechanism of hypercortisolism in depression and in Cushing's disease and to assist in the differential diagnosis of these disorders. As compared with controls (n = 34), depressed patients (n = 30) had basal hypercortisolism (P less than 0.001) that was associated with attenuated plasma ACTH responses to ovine corticotropin-releasing hormone (P less than 0.001). This indicates that in patients with depression, the corticotroph cell in the pituitary responds appropriately to the negative feedback of high cortisol levels. In contrast, patients with Cushing's disease (n = 29) had plasma ACTH hyperresponsiveness to ovine corticotropin-releasing hormone (P less than 0.001), despite basal hypercortisolism (P less than 0.001), which indicates a gross impairment of the mechanism by which cortisol exerts negative feedback on the pituitary. Less than 25 percent of the patients with depression or Cushing's disease had peak ACTH responses that overlapped. We conclude that the pathophysiologic features of hypercortisolism in depression and Cushing's disease are distinct in each of the disorders and that the ovine corticotropin-releasing hormone stimulation test can be helpful in their differential diagnosis.

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Objective-This study assessed the incidence, severity, and course of expressed suicidal intent in depressed patients who were treated with ECT. The data are from the first phase of an ongoing, collaborative multicenter study, the overall aim of which was to compare continuation ECT with pharmacotherapy in the prevention of relapse after a successful course of ECT.Method-Suicidal intent, as expressed by patients during an interview, was scored at baseline and before each ECT session with item 3 on the 24-item Hamilton Depression Rating Scale in 444 patients with unipolar depression.Results-One hundred thirty-one patients (29.5%) reported suicidal thoughts and acts (score of 3 or 4) at baseline. Scores decreased to 0 after 1 week (three ECT sessions) in 38.2% of the patients, after 2 weeks (six ECT sessions) in 61.1%, and in 80.9% at the end of the course of treatment.Conclusions-Expressed suicidal intent in depressed patients was rapidly relieved with ECT. Evidence-based treatment algorithms for major depressive mood disorders should include dichotomization according to suicide risk, as assessed by interview. For patients at risk, ECT should be considered earlier than at its conventional "last resort" position.Suicide and suicide attempts are risks of the major psychiatric illnesses, with mortality rates markedly higher than for the general population (1). A lifetime risk of 15% for suicide was the conclusion of a meta-analysis of hospitalized patients by Guze and Robins (2). A reanalysis of studies of suicide in affective illness in three groups of patients-outpatients, inpatients, and suicidal patients-found a risk of those ever hospitalized of 8.6% (3). Other studies confirmed the risk of suicide to be particularly high in hospitalized depressed patients (4-6). Profound hopelessness, hypochondriacal ruminations or delusions, and thoughts of suicide or self-harm during depression predict future suicide (7).Antidepressant medications are the principal agents used to treat affective disorders today. Their impact on suicide risk is not well defined, however, and they are generally viewed as less effective than ECT in relieving depression and suicidal thoughts. Hordern et al. (8) reported no suicides at the 6-month follow-up in 34 women treated with ECT but found two in the 84 patients treated with antidepressants (2.4%). Avery and Winokur (9) suicidal behavior in the 6 months following the treatment of depression in 519 patients. Suicide attempts were recorded in 0.8% of the ECT patients compared to 4.2% of those who had received "adequate" and 7% "inadequate" antidepressant medication treatment. Khan et al. (10) found antidepressant drugs to be no more effective than placebo in reducing suicide rates in seriously ill depressed patients.The experience with ECT is also unclear. A comparison of the frequency of suicides in different decades found decreased rates when ECT was the dominant treatment for mental illness (11). An examination of the records of 1,397 completed suicides in Finland within a 12-m...