Van Melle et al (2007) found no difference in efficacy and cardiac prognosis between treatment with antidepressive medication and care as usual in patients with depression after myocardial infarction. Carney & Freedland (Reference Carney and Freedland2007) commented that the lack of difference in efficacy prohibits the demonstration that effective treatment of depression improves survival. They emphasised the need for developing highly efficacious treatments for depression following myocardial infarction. Such a treatment, however, already exists, as electroconvulsive therapy (ECT), and has been shown to have superior efficacy compared with antidepressive medication (ECT UK Review Group, 2003).

A trial using ECT as an intervention will more likely find a superior efficacy compared with treatment as usual and may demonstrate that effective depression treatment improves survival. Because of concerns about the cardiac risks some text-books do not recommend the use of ECT within 3 months of myocardial infarction. Zielinski et al (Reference Zielinski, Roose and Devanand1993) found a higher rate of cardiac complications during ECT in patients with a pre-existing cardiac abnormality compared with patients with no pre-existing abnormality. Most complications, however, were transitory and did not prevent the completion of the ECT course. Rice et al (Reference Rice, Sombrotto and Markowitz1994) found that ECT increased the risk of minor but not severe complications. They pointed to the advances in ECT techniques which have resulted in improved safety in cardiac patients. The risk of ECT has to be weighed against the risk of an inadequate treatment of depression, which is known to increase mortality (van Melle et al, 2007). Considering the high risk of cardiac events of 13% in the 18 months following myocardial infarction (van Melle et al, 2007), which may partly be attributable to the inadequate treatment of depression, treatment with ECT could be safer because of its superior efficacy as an antidepressant.