Electroconvulsive therapy (ECT) is a medical procedure that uses a mild electrical current to induce a brief seizure in the brain. ECT is used to treat severe and treatment-resistant mental health conditions, such as depression, schizophrenia, bipolar disorder, and catatonia. ECT is performed under general anesthesia and with muscle relaxants to prevent pain and physical injury. ECT is one of the most effective and safe treatments for mental health, but it is often misunderstood and stigmatized by the public and the media.

ECT is a form of brain stimulation therapy that involves passing an electric current through electrodes attached to the scalp. The current causes a controlled seizure that lasts for about 15 to 30 seconds. The seizure affects the brain’s electrical activity and chemical balance, which may result in rapid and significant improvement of mental health symptoms. ECT is usually given two or three times a week for a total of six to 12 sessions, depending on the individual’s response and condition. ECT can be given as a first-line treatment or as a last resort when other treatments have failed or are not suitable.

ECT was first introduced in 1938 by Italian psychiatrists Ugo Cerletti and Lucio Bini, who experimented with electric shocks on animals and humans with epilepsy and schizophrenia. They observed that seizures could reduce psychotic symptoms and improve mood. ECT became widely used in the 1940s and 1950s as a treatment for various mental disorders, especially depression. However, ECT was often administered without anesthesia, consent, or proper monitoring, leading to serious side effects such as memory loss, brain damage, and fractures. ECT also gained a negative reputation due to its portrayal in movies, books, and media as a brutal and inhumane procedure.

In the 1960s and 1970s, ECT declined in popularity due to the emergence of new psychiatric medications, such as antidepressants and antipsychotics, and the rise of human rights movements and anti-psychiatry movements that criticized ECT as unethical and abusive. ECT also faced legal and regulatory challenges that restricted its use and availability. However, ECT did not disappear completely, as some clinicians and researchers continued to use it and improve it with scientific evidence and ethical standards. In the 1980s and 1990s, ECT experienced a resurgence as a safe and effective treatment for severe mental illnesses that did not respond to medications or other therapies. ECT also benefited from advances in technology, such as modern anesthesia, muscle relaxants, oxygenation, EEG monitoring, and electrode placement. ECT is now recognized by many professional organizations and guidelines as a valid and valuable option for mental health treatment.

The exact mechanism of how ECT works is not fully understood, but several theories have been proposed based on neurobiological evidence. Some of the possible mechanisms are:

• ECT alters the levels of neurotransmitters, such as serotonin, dopamine, norepinephrine, glutamate, and GABA, in the brain. These chemicals are involved in regulating mood, cognition, emotion, and behavior.
• ECT modulates the activity of brain regions and circuits that are implicated in mental disorders, such as the prefrontal cortex, the limbic system, the thalamus, and the hippocampus. These areas are responsible for executive functions, memory, learning, motivation, reward, stress response, and emotional regulation.
• ECT stimulates the growth of new brain cells (neurogenesis) and connections (synaptogenesis) in the hippocampus and other parts of the brain. This may enhance neuroplasticity and resilience to stress and trauma.
• ECT induces neurotrophic factors, such as brain-derived neurotrophic factor (BDNF), which promote neuronal survival, differentiation, maturation, and repair. BDNF also protects against neurodegeneration and inflammation.
• ECT reduces neuroinflammation and oxidative stress in the brain, which are associated with neuronal damage and dysfunction.
• ECT influences the expression of genes that regulate various aspects of brain function, such as synaptic transmission, neurotransmitter synthesis, receptor density, and signal transduction.

ECT has been extensively studied in clinical trials and meta-analyses and has shown to be highly effective for treating various mental health conditions, especially when other treatments have failed or are not tolerated. Some of the evidence for use are:

• ECT is considered the gold standard treatment for severe depression, particularly when accompanied by psychosis, suicidal ideation, or refusal to eat 1. ECT has been shown to achieve remission rates of 50% to 80% in depressed patients, compared to 10% to 30% with antidepressant medications 2. ECT also works faster than medications, with significant improvement seen within one to two weeks of treatment 3.
• ECT is also effective for treating schizophrenia and other psychotic disorders, especially when there is catatonia, a state of extreme immobility or agitation. ECT can reduce positive symptoms, such as hallucinations and delusions, as well as negative symptoms, such as apathy and social withdrawal. ECT can also augment the effects of antipsychotic medications and reduce the risk of relapse.
• ECT can treat bipolar disorder and other mood disorders that involve manic or mixed episodes. ECT can rapidly stabilize mood swings, reduce manic symptoms, such as euphoria, irritability, and impulsivity, and prevent recurrence of mood episodes. ECT can also be used as a maintenance therapy to prevent future episodes of depression or mania.
• ECT can help people with dementia who have severe agitation and aggression that are difficult to manage with medications or behavioral interventions. ECT can improve quality of life, cognitive function, and caregiver burden in these patients. ECT can also reduce the need for psychotropic medications and the risk of institutionalization.

ECT is generally safe and well-tolerated, but it may cause some side effects and adverse reactions that are usually mild and transient. Some of the common side effects are:

• Confusion: This is the most common side effect of ECT and usually occurs immediately after the treatment. It may last for a few minutes to several hours and may affect orientation, memory, attention, and concentration. Confusion is more likely to occur in older adults and those with pre-existing cognitive impairment.
• Memory loss: This is another common side effect of ECT and may affect both short-term and long-term memory. Short-term memory loss refers to difficulty remembering events that occurred around the time of the treatment, such as names, dates, or conversations. Long-term memory loss refers to difficulty remembering events that occurred before the treatment, such as personal or historical facts. Memory loss is usually temporary and improves over time, but some people may experience persistent or permanent memory gaps.
• Headache: This is a frequent side effect of ECT and may occur during or after the treatment. It is usually mild and responds well to analgesics.
• Nausea: This is a common side effect of ECT and may be related to the anesthesia or the seizure itself. It can be prevented or treated with antiemetics.
• Muscle soreness: This is a rare side effect of ECT and may be caused by the muscle relaxants or the seizure activity. It can be relieved with analgesics or massage.

Some of the rare but serious adverse reactions are:

• Cardiovascular complications: These include arrhythmias, hypertension, hypotension, myocardial infarction, and cardiac arrest. They are more likely to occur in people with pre-existing heart disease or risk factors.
• Respiratory complications: These include hypoxia, aspiration, pneumonia, and pulmonary edema. They are more likely to occur in people with pre-existing lung disease or risk factors.
• Prolonged seizure: This refers to a seizure that lasts longer than 2 minutes or does not stop spontaneously. It can cause brain damage, status epilepticus, or death. It can be treated with anticonvulsants or anesthesia.

There are no absolute contraindications for ECT, but some conditions may increase the risk of complications or require special precautions. Some of these conditions are:

• Brain tumor, aneurysm, stroke, or intracranial hemorrhage: These may increase the risk of bleeding, edema, or herniation during ECT.
• Recent neurosurgery or head trauma: These may increase the risk of infection, hematoma, or dehiscence during ECT.
• Severe cardiovascular disease: This may increase the risk of arrhythmias, ischemia, or infarction during ECT.
• Severe pulmonary disease: This may increase the risk of hypoxia, aspiration, or pneumonia during ECT.
• Pregnancy: This may increase the risk of fetal distress, miscarriage, or preterm labor during ECT.

ECT has many advantages over other treatments for mental health, such as medications, psychotherapy, or other brain stimulation techniques. Some of these advantages are:

• Efficacy: ECT is one of the most effective treatments for mental health, especially for severe and treatment-resistant conditions that do not respond to other treatments. 
• ECT has high remission rates and low relapse rates for depression and other mental disorders, compared to medications or psychotherapy.
• Speed: ECT works faster than medications or psychotherapy, with significant improvement seen within one to two weeks of treatment. ECT can be lifesaving for people who are suicidal, catatonic, or malnourished due to their mental illness.
• Safety: ECT is safe and well-tolerated, with minimal and transient side effects. ECT does not cause brain damage, personality change, or cognitive impairment. ECT is performed under controlled and monitored conditions, with modern anesthesia and muscle relaxants to prevent pain and injury.
• Suitability: ECT is suitable for people who cannot take medications due to allergies, interactions, side effects, or pregnancy. ECT is also suitable for people who do not benefit from or comply with medications or psychotherapy. ECT can be tailored to the individual’s needs and preferences, such as the type, frequency, and duration of treatment.
• Accessibility: ECT is widely available and accessible in most countries and regions. ECT can be performed in hospitals, clinics, or outpatient settings. ECT does not require extensive preparation or follow-up care.

ECT also has some disadvantages and limitations over other treatments for mental health, such as medications, psychotherapy, or other brain stimulation techniques. Some of these disadvantages are:

• Stigma: ECT is often misunderstood and stigmatized by the public and the media as a barbaric and outdated procedure. ECT is associated with negative stereotypes, myths, and fears that may deter people from seeking or accepting it. ECT may also face social and legal barriers that restrict its use and availability.
• Memory loss: ECT may cause temporary or permanent memory loss that can affect personal or professional functioning. Memory loss may be distressing or frustrating for some people and may affect their self-esteem or identity. Memory loss may also impair the ability to recall the benefits of ECT or consent to future treatments.
• Cost: ECT may be expensive and not covered by insurance or public health systems. ECT may require multiple sessions and frequent visits to the hospital or clinic. ECT may also incur additional costs for transportation, accommodation, anesthesia, or medication.
• Maintenance: ECT may require maintenance treatments to prevent relapse or recurrence of mental health symptoms. Maintenance treatments may involve ongoing ECT sessions or medications that may have side effects or interactions. Maintenance treatments may also interfere with daily activities or routines.
• Uncertainty: ECT may not work for everyone or for every condition. ECT may have variable or unpredictable outcomes that depend on individual factors, such as age, gender, diagnosis, severity, duration, co-morbidity, medication use, electrode placement, stimulus intensity, seizure quality, and treatment course. ECT may also have unknown or long-term effects on the brain that are not fully understood.

ECT is a valuable and effective treatment for mental health that can improve the lives of many people who suffer from severe and treatment-resistant conditions. ECT has many advantages over other treatments, such as efficacy, speed, safety, suitability, and accessibility. However, ECT also has some disadvantages and limitations that need to be considered, such as stigma, memory loss, cost, maintenance, and uncertainty. Therefore, ECT should be used as a part of a comprehensive and individualized treatment plan that involves informed consent, careful assessment, close monitoring, and ongoing support.

: American Psychiatric Association (2010). The practice of electroconvulsive therapy: Recommendations for treatment, training, and privileging (2nd ed.). Washington, DC: American Psychiatric Publishing.

: Kellner CH, Greenberg RM, Murrough JW, Bryant SG, Coffey CE (2012). A meta-analysis of randomized controlled trials of electroconvulsive therapy in treatment-resistant depression. Depression and Anxiety, 29(10), 881–890.

: UK ECT Review Group (2003). Efficacy and safety of electroconvulsive therapy in depressive disorders: A systematic review and meta-analysis. The Lancet, 361(9360), 799–808.

: Sackeim HA (2001). The cognitive effects of electroconvulsive therapy in community settings. Neuropsychopharmacology, 24(5), 563–573.

: Fink M (2014). Electroconvulsive therapy: A guide for professionals and their patients (2nd ed.). Oxford: Oxford University Press.