All patients received ECT using a Mecta Spectrum 5000Q (Tualatin, OR). All unilateral treatments utilized the D’Elia placement. As part of routine clinical practice for all twelve psychiatrists in the ECT group during the study period, seizure threshold was determined by dose titration for the first treatment. From 2005 through October 2010, a range of starting doses and titration steps were used at the discretion of the treating psychiatrist. Around this time an informal consensus emerged among treating psychiatrists setting the default starting dose for titrations at 19.2 mC (pulse width 0.3 ms, frequency 20 Hz, amplitude 800 mA, duration 2 s), with subsequent steps of the titration doubling duration according to the MECTA ultrabrief titration tables (step 2: 4s, 38.4 mC; step 3: 8s, 76.8 mC). Subsequent treatments were then targeted at 6× seizure threshold based on the MECTA ultrabrief tables. Generally methohexital was used as the anesthetic agent, but etomidate, propofol, or ketamine were used at the discretion of the treating psychiatrist or anesthesiologist. Succinylcholine was used as the muscle relaxant. Seizure presence and duration were determined based on two lead frontomastoid or bifrontal EEG and by observing motor response using the “cuff method” of inflating a BP cuff on one calf prior to muscle relaxant administration. If a seizure was ongoing at 120 seconds, propofol was given.