Electroconvulsive Therapy (ECT) for Depression

Medically Reviewed by Jabeen Begum, MD on June 25, 2024
Written by Debra Fulghum Bruce, PhD, Marijke Vroomen Durning, RN
11 min read

When medication fails to ease the symptoms of clinical depression, there might be other options to try, such as electroconvulsive therapy (ECT).

Electroconvulsive therapy (ECT) is one of the safest and most effective treatments available for depression and bipolar disorder. Electrodes are placed on your scalp and a finely controlled electric current is applied while you are under general anesthesia. The current causes a brief seizure in the brain. ECT is one of the fastest ways to ease symptoms in patients who are severely depressed or suicidal. It's also very effective for patients who have mania or several other mental illnesses.

ECT is generally used when severe depression doesn’t respond to other forms of therapy. Or it might be used when patients pose a severe threat to themselves or others and it is too dangerous to wait until medications take effect.

Despite ECT being around for over 80 years, many people still don’t really understand it. Often, the risks and side effects aren’t related to the treatment itself but to people not using the equipment as they should, the shocks not being administered properly, or those doing the treatment not being trained properly. It’s a misconception that ECT is a "quick fix" to use instead of long-term therapy or hospitalization. And it’s not true that patients are painfully "shocked" out of depression during ECT. Entertainment, news reports, and media coverage have driven the misinformation surrounding this treatment.

The history of ECT

ECT was first tried on a human in 1938, on a man with schizophrenia who was having a psychotic episode. The treatment was successful. By the 1940s, ECT became popular across the world. The treatment was improved and eventually became the go-to treatment for serious mental illness.

As research into mental health progressed, some scientists and doctors believed that ECT was cruel and shouldn’t be used, especially as new medications were developed. By the 1960s and 1970s, ECT fell out of favor and medications took over. However, by the 1980s, psychiatrists returned to ECT for some of their patients. While it’s not usually a standard treatment, ECT has its place for people with serious mental disorders that don’t respond to medications or severe depression that could be life-threatening.

Many people with depression see good results when they take antidepressant medications. Unfortunately, these medications don’t work for everyone. If someone with depression takes their medications as prescribed and has tried at least two different types of antidepressants, they could have treatment-resistant depression.

ECT works by changing some of the neural (nerve) networks in your brain. This isn’t too different from how antidepressant drugs work. While medications work by inhibiting (blocking) how some cells in your brain are absorbed, they also affect your neural network. ECT works much more quickly than medications, which is why it can be a first-choice treatment for people who are severely ill and who may harm themselves or others.

Going for your first ECT treatment may be frightening, so here are some tips to help you prepare for the procedure.

After your doctor or psychiatric team has done a thorough psychiatric assessment to see if you are a candidate for electroconvulsive therapy, they will need to review your medical history to see if you have other medical conditions.

Once that is done, you’ll need a physical examination and some tests to make sure you’re healthy enough to have the treatment. The tests may include:

  • Electrocardiogram (EKG). This test checks your heart’s electrical function.
  • Blood tests. Blood tests may include a complete blood count (CBC), thyroid function tests, and kidney function tests, among others.
  • Chest X-ray. If your doctor is concerned that you may have heart disease, you may be sent for a chest X-ray before you have ECT.
  • CT scan. This scan may show some biological reason, such as a brain abnormality, to explain your symptoms, which means that ECT wouldn’t be the right treatment.

Also before having ECT, you or someone who has your medical power of attorney must sign a consent form. This tells the doctor that you are giving your informed consent to have the procedure. You do have the right to refuse consent for the treatment. But if your doctor believes that you are too ill to make that decision, the hospital can ask for a court-appointed guardian to do so.

There are several steps before you have the actual procedure. Here is what will typically happen:

  • Intravenous (IV): A member of the staff will start an IV so you can get a muscle relaxant and anesthesia, which will help you through the procedure
  • ECG: Someone will place leads on your chest so your heart can be monitored throughout the procedure. 
  • Electroencephalogram (EEG): You will also feel someone attaching EEG leads to your scalp so the doctor can monitor your brain waves.
  • Bite guard: Someone will place a mouth guard or bite guard between your teeth. This will protect your teeth.
  • Electrodes: Finally, the electrodes for the ECT are placed on your scalp. 

Once all is ready, a finely controlled electric current is sent through the electrodes to your brain. This current causes a brief seizure in your brain.

Because your muscles are relaxed, the only visible effects of the seizure are usually a slight movement of your hands and feet. The doctor knows that the current went through because the EEG will show the brain activity caused by the seizure. You’ll wake up minutes later and you won’t remember the treatment or events surrounding it. You may feel confused, but this typically lasts for only a short period. Patients undergoing ECT are carefully monitored during the treatment.

ECT is usually given up to three times a week for a total of 2 to 4 weeks.

Why do they use anesthesia for electroconvulsive therapy?

ECT shouldn’t be done without muscle relaxants and general anesthesia. Muscle relaxants lower the chances of your muscles being injured or strained when your body has a seizure. The anesthesia prevents you from feeling any pain or discomfort from the procedure.

With ECT, an electrical stimulation is delivered to the brain, which causes a seizure. For reasons that doctors don't completely understand, this seizure helps relieve the symptoms of depression. ECT doesn't cause any structural damage to the brain.

The procedure can be done in the hospital or an outpatient clinic.

The number of required sessions varies. Many people have 6 to 12 sessions given two to three times per week for several weeks. After your treatment is done, you might still need antidepressant medications and therapy to prevent your depression from returning.

 

According to the American Psychiatric Association, ECT can be beneficial and safe when a patient:

  • Needs a rapid treatment response, such as in pregnancy
  • Refuses food, leading to malnutrition
  • Has depression that is resistant to antidepressant drugs
  • Has other medical conditions that prevent the use of antidepressant medication
  • Is in a catatonic stupor
  • Has depression with psychotic features
  • Has bipolar disorder, including both mania and depression
  • Has symptoms of mania
  • Has a severe risk of suicide
  • Has had a previous response to ECT
  • Has psychotic depression or psychotic mania
  • Has major depression

You might not be a candidate for ECT if you have any of these conditions:

  • A recent heart attack
  • Unstable heart disease
  • Increased pressure in the brain
  • Recent bleeding in the brain, caused by a stroke or aneurysm, for example
  • Chronic obstructive pulmonary disease (COPD) or any other serious respiratory illness

ECT should also not be given to a child younger than 11 years. Although it can be used in children aged 11 to 18, it’s rarely effective.

Like all medical procedures, there are some risks and side effects that some people may experience if they have electroconvulsive therapy. They could include:

  • Confusion. Some people, especially older adults, may feel confused for a few hours after their ECT procedure. There’s a risk that it could last a few days, but this is rare.
  • Memory loss. Retrograde amnesia — memory loss of events right before the treatment — could happen. Rarely, the memory loss could cover a larger span of a few weeks or months. Memory loss could also happen for events during the weeks you have treatment.
  • Nausea
  • Headaches, jaw pain, or muscle aches
  • Complications from anesthesia

After ECT, patients may have temporary side effects such as confusion, disorientation, and memory loss. These side effects usually improve within a few days to a few weeks. Some patients may also have headaches, muscle aches, and nausea.

Patients will be required to follow safety precautions such as avoiding driving or operating heavy machinery until cleared by the health care provider. They should also avoid alcohol and medications that can interact with the anesthesia used during the procedure.

It's important to have realistic expectations about recovery time and outcome, as the recovery process will be different for each person.

There are other treatments that are similar to ECT.

Transcranial magnetic stimulation (TMS)

TMS was approved by the FDA in 2008 for treatment-resistant depression. It creates a magnetic field for a much smaller electric current to reach a specific part of the brain, without causing seizure or loss of consciousness. Pulses are delivered through your forehead.

TMS works best in patients who didn't benefit from one antidepressant treatment but have not tried two or more treatments. Unlike ECT, you don’t need to be sedated while having TMS. It’s given in an outpatient setting and must be done four or five times a week for 4 to 6 weeks.

Research shows that TMS produces few side effects and is safe and effective for medication-resistant depression. However, it’s only about half as effective as ECT.

Vagus nerve stimulation (VNS)

A vagus nerve stimulator (VNS) is an FDA-approved device that may help adults with long-term or recurrent major depression. Some who undergo VNS may have been taking many medications for depression but continue to have symptoms.

The small stimulator is implanted under your skin at the collarbone. It runs under the skin to the vagus nerve in your neck. The device sends electrical pulses to stimulate the brain.

Alternative treatments

Alternative treatments can sometimes provide relief from mild depression, but they don’t usually help with severe depression, which is the type that ECT would treat.

If you’re interested in trying some alternative treatments, speak with your psychiatrist to see how they can go along with your ECT treatment. Some examples of therapies include guided imagery, yoga, hypnosis, biofeedback, aromatherapy, and herbal remedies.

Experimental therapies are treatments that are being studied for their safety and effectiveness in treating depression. Most doctors aren’t using them yet though. If you’re interested in experimental studies, speak with your doctor to see if there is a clinical trial near you or doctors who are trying experimental therapies.

Some experimental therapies currently under investigation for treating depression include:

Hormone replacement therapy (HRT) in women. Depression is more common in women than in men. Premenstrual syndrome (PMS), premenstrual dysphoric disorder (PMDD), post-childbirth (postpartum), and menopause are all linked to sudden drops in hormone levels. Currently, HRT helps some women get relief from symptoms of menopause, such as night sweats and hot flashes. HRT can also help prevent bone-thinning osteoporosis. But doctors don’t yet know how hormones can contribute to depression.

Intravenous or internasal ketamine. The anesthetic agent ketamine is approved for the treatment of severe depression. It’s been shown to provide a rapid (within hours) improvement in depression and is effective in some patients.

Riluzole (Rilutek, Tiglutik). Originally used to treat motor neuron disorders such as amyotrophic lateral sclerosis (ALS, or Lou Gehrig's Disease), this medicine has also been shown to affect neurotransmitters involved in depression. Early studies show that it might have promise in treating depression that is unresponsive to more traditional medicines.

If you have electroconvulsive therapy and it successfully treats your depression, keep in mind that depression can return over time. Psychotherapy and/or maintenance antidepressant medications (those you take over a long period) can help reduce the risk of depression coming back. Psychotherapy does this by adjusting the beliefs, perceptions, and behaviors that contribute to your depression. If you do feel that your symptoms are coming back though, seek help again as soon as possible. The earlier you treat depression, the better the chances of successful treatment.

The outlook for people who have depression and seek treatment is very promising. By working with a qualified and experienced mental health care professional, you can regain control of your life. Finding the right treatment may take some time, but it is possible.

Once you’ve decided to get help for your depression, the next step is finding it. If you are in an immediate or severe crisis though, this is a medical emergency. Call 911 for help or the 988 Suicide & Crisis Lifeline.

Here are some ideas for you to find the help you need:

  • Speak with your primary care professional. If your condition is severe, they may refer you to a psychiatrist. Otherwise, they may refer you to a psychologist, social worker, or a therapist.
  • Ask your insurance company for recommendations. 
  • Reach out to national organizations. There are several groups online that can help you find a mental health professional in your area.
  • Check to see if your employer has an Employee Assistance Program.
  • If you’re a student, check if your college or university provides mental health services or can refer you to some.

 

Many people live with depression. If you have severe depression, you aren’t alone. If your depression doesn’t respond to medications (treatment-resistant depression) or is very serious and needs to be treated immediately, electroconvulsive therapy (ECT) might be the answer. This therapy helps your brain do a kind of reset and ease the depression. You won’t feel anything while having ECT because you will be put to sleep with a general anesthetic while it’s done. You may have some side effects afterward, but the long-term results of ECT are good for most people who have it.

Is ECT painful? ECT isn’t painful. You are given a general anesthetic before the procedure starts so you will be asleep until it is over.

What is the mechanism of action of ECT therapy? The shocks delivered for ECT make changes in the nerve pathways, kind of resetting the brain.

How long does ECT last? The treatment itself lasts about 20 minutes, but the entire process, including preparation and waking up after, takes about 1 hour.

What happens after the first ECT treatment? You may not feel any effects on your depression after the first treatment. It’s not unusual for it to take a few treatments before you feel a response. You may feel achy and sore, and you may not remember your treatment. These are some of the possible side effects of electroconvulsive therapy.