To the Editor We read with great interest the recent Review by Dr Simon and colleagues on management of depression in adults.1 Although we commend the authors for their accomplishment in synthesizing large amounts of evidence in this field, we consider the article鈥檚 focus on the management of the more severe forms of depression to be insufficient and therefore the title of the article to be somewhat misleading. Specifically, although the authors spend several paragraphs discussing complementary and alternative forms of treatment with small to medium effect sizes, they only briefly mention electroconvulsive therapy (ECT), which they consider a third-line therapeutic option. This is surprising because ECT has been established for decades as the most effective treatment for acute severe depression, with effect sizes compared with medication or sham ECT greater than 0.80 and particularly high remission rates in psychotic depression.2,3 Hence, when used prudently and for the right patients, ECT ranks among the most powerful interventions not only in psychiatry, but in all of medicine. It is furthermore superior in efficacy to other interventions mentioned by the authors, such as transcranial magnetic stimulation3 and ketamine.4