Both Le Strat & Gorwood and Bharadwaj & Grover comment on the finding of a decrease in mortality in ECT-treated patients. In Denmark, all psychiatric patients are given a thorough medical assessment prior to any somatic treatment. This is partly because of the well-known cardiac contraindications for the use of tricyclic antidepressants which were widely used during the study period from 1976 to 2000, as the selective serotonin reuptake inhibitors (SSRIs) were only available in the latter part of the period described. Furthermore, SSRIs were generally considered less effective than tricyclic antidepressants or ECT in patients with severe depression. Accordingly, ECT was often used in patients with contraindications for tricyclic antidepressants. We are aware that this notion is at variance with several British guidelines (e.g. National Institute for Clinical Excellence, 2003) but it is in accordance with Danish and American Psychiatric Association guidelines, which state that the only contraindications to ECT are cerebral and other aneurysms. In Denmark, a preponderance of patients with medical illness is thus found among ECT-treated patients compared with those treated with tricyclic antidepressants and we therefore maintain our conclusion.

Drs Bharadwaj and Grover point out that admission status and time since discharge are important confounders. We fully agree and have hence adjusted for these variables in the analysis. The variables in Table 3 on risk of suicide in ECT recipients were mutually adjusted but this was not mentioned specifically in the footnote.

The number of patients dying by suicide in the first week after ECT discontinuation was small, and therefore our results should be interpreted with caution, as we mention in the discussion. Electroconvulsive therapy is often administered to patients who are assessed to be suicidal and we acknowledge that this could introduce selection bias (confounding by indication), which we also mention in our paper. These are the reasons why we concluded that: ‘the increased suicide rate among ECT patients shortly after treatment is probably a result of bias’ and we therefore disagree that the validity of the study is questionable regarding suicide rates after ECT.

A more in-depth description of the ECT patients can be found in a paper based on the same data (Reference Munk-Olsen, Laursen and VidebechMunk-Olsen et al, 2006).