Failure to respond to adequate pharmacological treatment for major depression is now the most common indication for the use of electroconvulsive therapy (ECT). The advantages of ECT with respect to both speed and quality of response are clinically important issues, but surprisingly few studies have examined the efficacy of ECT in relation to newer antidepressant agents such as selective serotonin reuptake inhibitors (SSRIs). A total of 39 subjects with major depression and with at least two failed antidepressant trials (mean 4.9 trials) were randomized to either paroxetine treatment (n=18) or right unilateral (RUL) ECT (n=21). Up to the end of the study treatment we found a reduction in the HAMD score of 59% for the ECT group and of 29% for the paroxetine group (P<0.001 paired t-test). In the ECT group, 71% of subjects fulfilled the response criteria (at least a 50% decrease in total HAMD score). The present study found ECT to be superior to paroxetine in medication-resistant major depression, in terms of both degree and speed of response.

The significance of the alteration in circadian rhythm in endogenous depression is discussed. 23 patients with endogenous depression, 11 patients with neurotic depression and 23 healthy subjects were deprived of sleep for one night. Those with endogenous depression responded favourably though the duration of the improvement was variable. In those with neurotic depression the response was less reliable and when it occurred the improvement was less marked. In one patient the condition was made worse. Patients with endogenous depression showed a rise in systolic bloodpressure in the ophthalmic artery following sleep deprivation. This did not occur in those with neurotic depression nor in healthy subjects. Sleep deprivation is to be recommended for the treatment of endogenous depression both in the initial stage and in later stages when the condition has proved resistant to thymoleptic agents.

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