Background: Electroconvulsive therapy (ECT) is considered to be the most effective treatment in severe major depression. The identification of reliable predictors of ECT response could contribute to a more targeted patient selection and consequently increased ECT response rates.Aims: To investigate the predictive value of age, depression severity, psychotic and melancholic features for ECT response and remission in major depression.Method: A meta-analysis was conducted according to the PRISMA statement. A literature search identified recent studies that reported on at least one of the potential predictors.Results: Of the 2193 articles screened, 34 have been included for meta-analysis. Presence of psychotic features is a predictor of ECT remission (odds ratio (OR) = 1.47,P= 0.001) and response (OR = 1.69,P< 0.001), as is older age (standardised mean difference (SMD) = 0.26 for remission and 0.35 for response (P< 0.001)). The severity of depression predicts response (SMD = 0.19,P= 0.001), but not remission. Data on melancholic symptoms were inconclusive.Conclusions: ECT is particularly effective in patients with depression with psychotic features and in elderly people with depression. More research on both biological and clinical predictors is needed to further evaluate the position of ECT in treatment protocols for major depression.Declaration of interest: None.

For various reasons, compulsory admissions of psychiatric patients should be prevented as far as possible. Being compulsorily admitted has a strong effect on patients and their relatives and can be traumatic.¹ A European multicenter study² showed that 30% to 50% of patients who have been compulsorily admitted undergo coercive interventions, such as enforced medication, seclusion, and restraint. Although the exact definition of compulsory admission might differ from country to country depending on the judicial context, a compulsory admission is always an admission against the will of the patient (according to local judicial procedures). Compulsory admission also conflicts with principles of autonomy, shared decision making, and recovery-focused care.^3,4 Fear of coercion may keep patients away from treatment.⁵ However, the consequences of compulsory admissions are not exclusively negative: they have also been associated with improvements in psychosocial functioning and better motivation for treatment.⁶ In cases of severe danger to self or others caused by a psychiatric condition, compulsory admission is commonly seen as justified and required.⁷

Objective: Several countries have developed Clinical Practice Guidelines regarding treatment of perinatal depressive symptoms and perinatal use of antidepressant. We aimed to compare guidelines to guide clinicians in best clinical practice. Methods: An extensive search in guideline databases, MEDLINE and PsycINFO was performed. When no guidelines were (publicly) available online, we contacted psychiatric-, obstetric-, perinatal- and mood disorder societies of all first world countries and the five largest second world countries. Only Clinical Practice Guidelines adhering to quality criteria of the Appraisal of Guidelines for Research and Evaluation instrument and including a systematic review of evidence were included. Data extraction focussed on recommendations regarding continuation or withdrawal of antidepressants and preferred treatment in newly depressed patients. Results: Our initial search resulted in 1094 articles. After first screening, 40 full-text articles were screened. Of these, 24 were excluded for not being an official Clinical Practice Guidelines. In total, 16 Clinical Practice Guidelines were included originating from 12 countries. Eight guidelines were perinatal specific and eight were general guidelines. Conclusion: During pregnancy, four guidelines advise to continue antidepressants, while there is a lack of evidence supporting this recommendation. Five guidelines do not specifically advise or discourage continuation. For new episodes, guidelines agree on psychotherapy (especially cognitive behavioural therapy) as initial treatment for mild to moderate depression and antidepressants for severe depression, with a preference for sertraline. Paroxetine is not preferred treatment for new episodes but switching antidepressants for ongoing treatment is discouraged (three guidelines). If mothers use antidepressants, observation of the neonate is generally recommended and breastfeeding encouraged.