Recent evidence indicates that in major depressive disorder, the magnitude by which electrical dosage exceeds the individual's seizure threshold is critical to the efficacy of unilateral electroconvulsive therapy, and to the speed of response of bilateral electroconvulsive therapy. Electroconvulsive therapy appears to be as effective, if not more effective, in elderly people compared with young adults, although careful attention needs to be paid to cardiovascular status and risk factors. Literature reviews provide strong support for the efficacy of electroconvulsive therapy in mania, although there are few controlled studies. Brain-imaging studies reveal a high prevalence of white-matter abnormalities in geriatric major depression, and further work is needed to clarify their clinical correlates
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