The articles in this debate address two separate but overlapping questions regarding the management of severe depression in older adults: (1) Is electroconvulsive therapy (ECT) an efficacious and safe treatment, and (2) What is the role of psychotherapy? That the first question is asked at all may come as a surprise to the many practitioners of geriatric psychiatry who consider ECT to be an indispensable part of their therapeutic tool kit. Yet, Wilkinson argues that the evidence supporting the efficacy of ECT in the elderly is “sparse” and derived from studies that are “of poor quality.” He provocatively states that psychotherapy “is at least as important as ECT” in the management of severe late-life depression, and advocates the more widespread use of psychotherapy to treat severe depression in older adults, including individuals admitted to psychiatric inpatient units. There are two issues here. First, what is severe depression? Second, what constitutes sufficient evidence to support the use of ECT or psychotherapy in severe depression in late life?