Psychotic symptoms in depression are indicators of severity and poor prognosis. It usually requires psychopharmacotherapy with antidepressants and antipsychotic agents and it may even require electroconvulsive therapy (ECT).

To review the indications of ECT in major depression through the study of a clinical case of a patient admitted in an indoor psychiatric unit.

A 64-year-old woman diagnosed as bipolar affective disorder 20 years ago. Her first manic episode required hospitalization. Afterwards, she remained clinically stable for 18 years with pharmacotherapy with lithium. Lately she was admitted due to a major depressive episode with psychotic features (injury delusions, ruin and catastrophe). Antidepressant and antipsychotic treatment was added, improving her symptoms. However, she had to be readmitted two months later with severe psychotic symptoms that did not improve with pharmacological treatment. ECT was added to her treatment. She improved after a few sessions. During the last years, she has presented depressive episodes with psychotic symptoms at least once a year, and all of them have required ECT.

ECT is an alternative to pharmacological therapy in depression with psychotic symptoms in patients with no response to drugs. According to studies and clinical practice, ETC has been effective as we see in this case. Therefore, ECT is a technique to consider in major depression, not only in patients who do not respond to drug therapy but also in those who do not tolerate psychopharmacological, who suffer from severe or psychotic symptoms, suicide thoughts or those, psychomotor agitation or stupor.