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Electroconvulsive therapy (ECT) is frequently considered only after multiple failed medication trials, in part because of its expense. To learn how its effectiveness might balance its costs, researchers developed a mathematical model based on the STAR*D trial's four-step treatment structure (which started with citalopram) and results. The investigators used data from multiple studies evaluating cost, efficacy, and quality-adjusted life-years (QALYs) to simulate the cost-effectiveness of ECT when introduced after up to five trials of pharmacotherapy or psychotherapy (or both) in patients with refractory depression and mean age of 41. The model assumed 8 acute ECT sessions in the first month and 16 maintenance treatments annually, based on pu…