Towards Precision ECT: A systematic review of epigenetic biomarkers in treatment-resistant depression

Electroconvulsive therapy (ECT) remains one of the most effective treatments for patients with treatment-resistant major depressive disorder (TR-MDD). However, the biological mechanisms underlying its therapeutic effects are not yet fully understood. Epigenetic regulation has recently emerged as a promising field for elucidating the molecular underpinnings of ECT response. This systematic review aimed to identify and synthesize existing studies investigating epigenetic biomarkers associated with ECT outcomes in human populations. A systematic review was conducted in PubMed and Scopus for studies published between January 2015 and March 2025. The review adhered to PRISMA 2020 guidelines. Inclusion criteria were: (1) original, peer-reviewed studies; (2) investigation of ECT-induced effects on epigenetic markers; and (3) diagnosis of major depressive disorder. Extracted data included epigenetic targets, patient characteristics, ECT parameters, and clinical outcomes. Risk of bias and heterogeneity were taken into account in the synthesis. Eleven studies met the inclusion criteria, encompassing a total of 498 patients with TR-MDD. Across studies, 31 promising epigenetic biomarkers were identified, including genes involved in neuroplasticity, hypothalamic-pituitary-adrenal (HPA) axis regulation, inflammation, immune signaling, and non-coding RNAs. DNA methylation and microRNA (miRNA) expression were the most frequently studied mechanisms. No studies to date have investigated histone modifications in human subjects undergoing ECT. This systematic review provides preliminary evidence that epigenetic mechanisms-particularly DNA methylation and miRNA expression-may play a role in modulating response to ECT in patients with TR-MDD. While these findings offer important insights for clinical stratification and precision psychiatry, they are limited by small sample sizes and methodological variability. Larger, standardized, and longitudinal studies are needed to validate these initial findings and support translational applications.