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Evidence for the efficacy of electroconvulsive therapy (ECT) in treating major depressive episodes, already compelling at the time the guideline was published, has been strengthened by additional findings. Recent meta-analyses have highlighted the superior efficacy of ECT relative to sham treatment and also relative to pharmacotherapies for depression (57, 58). In depressed patients who received an acute course of ECT, data from the Consortium for Research in ECT have shown that thrice-weekly bilateral ECT is associated with rapid initial response and high rates of sustained response and remission (59). In comparison with bilateral ECT, right unilateral ECT has been associated with fewer cognitive effects (60, 61), particularly in autobiographical memory (62). However, as with bilateral ECT, cognitive effects vary with the extent to which the electrical stimulus exceeds the seizure threshold (60). In addition, the overall efficacy of unilateral ECT appears to be less than that with bilateral ECT (57). Several additional studies highlight the diminished efficacy of barely suprathreshold electrical stimulation with right unilateral electrode placement (60, 61, 63) and a corresponding need to administer right unilateral ECT at stimulus intensities that are at least six times the initial seizure threshold (64). Additional details on the clinical use of ECT in the treatment of major depression can be found in the 2001 revision of the APA's The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging (64).

Although other somatic treatments, including repetitive transcranial magnetic stimulation, magnetic seizure therapy, and vagal nerve stimulation, have also been studied over the past 5 years, evidence is not yet sufficient to recommend their use in routine clinical practice.

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