This is a revision of a Geriatric Mental Health Academic Award. This Academic Investigator Award will provide the educational experience and mentorship necessary for the principal investigator to develop as a contributing clinical scientist in the areas of electroconvulsive therapy (ECT) and depression in the elderly. Clinical depression occurs commonly in the elderly. ECT is the treatment of choice when the elderly cannot tolerate or do not respond to antidepressant medication. The primary side effect of ECT in the elderly is reversible cognitive impairment. The cognitive side effects can be reduced by using brief pulse, right unilateral ECT. More recent efforts to further improve the efficacy of ECT while reducing the cognitive side effects have focused on strategies to dose the intensity of the electrical stimulus to correspond to the patient's requirement for an electrically induced seizure (seizure threshold). The seizure threshold varies widely between subjects; a stimulus dose far in excess of threshold contributes to side effects while too low a dose will not have antidepressant activity. This project will randomize elderly depressed patients to receive either a fixed, high dose stimulus (which is the standard in the U.S.) or a stimulus dose titrated only moderately in excess of the individual's seizure threshold. The difference between these two groups in the rate of antidepressant response and the severity of cognitive side effects will be measured. I predict that titrated ECT will result in less cognitive side effects in the elderly than fixed dose ECT. The academic portion of this proposal will provide for class work in statistics and epidemiology. Further, this proposal will allow active study and dialogue with Drs. Burton Reifler, Harold Sackeim, Richard Weiner, David Reboussin, and Frank Wood who are experts in the areas of dementia, depression, ECT, and biostatistics cognitive testing. Completion of the academic portion of this proposal will provide the tools necessary to complete the scientific project and develop as an investigator in geriatric depression and treatment.