Depression is one of the most common reversible psychiatric disorders in the medically ill hospitalised elderly. Because of its adverse impact on quality of life, compliance with medical therapy, motivation towards recovery, and survival itself, depression requires rapid diagnosis and comprehensive management. Because of the risks attendant on the use of antidepressants and electroconvulsive therapy (ECT) in this population, medical and psychosocial strategies are of paramount and primary importance in the treatment of most critically ill depressed elderly individuals. These include adequate treatment of reversible medical illness, provision of psychological support, mobilisation of community resources, and involvement of family and social support networks. When depression is severe or associated with marked suicidal ideation, however, these four strategies may need to be carried out concurrently with biological therapies. After ensuring adequate cardiac, liver, and renal function, antidepressant therapy is best initiated at a low dosage (secondary amine preferred) and gradually titrated upward following serum concentrations carefully and monitoring for anticholinergic, hypotensive and cardiac adverse effects. If antidepressant therapy is not tolerated or is unsuccessful, then psychiatric consultation should be obtained and ECT considered, particularly if the patient is well enough to undergo repeated episodes of brief general anaesthesia.