Information about ECT
This leaflet is for anyone who wants to know more about ECT
(Electro-convulsive therapy). It looks at how ECT works, why it is
used, its effects and side-effects, and alternative treatments.
Although a safe and effective treatment, ECT remains
controversial and we have included some of the different views
Where there are areas of uncertainty, we have listed other
sources of information that you can use. Important concerns are the
effectiveness and side-effects of ECT and how it compares with
other treatments. At the time of writing, these references are
available free and in full on the Internet.
What is ECT?
ECT is a treatment for a small number of severe mental
illnesses. It was developed in the 1930s and was used widely during
the 1950s and 1960s for a variety of conditions. It is now only
used for fewer, more serious conditions.
An electrical current is passed through the brain to produce an
epileptic fit – hence the name, electro-convulsive. On the face of
it, this sounds odd. The idea developed in the days before
effective medication. Doctors noticed that some people with
depression or schizophrenia, who also had epilepsy, seemed to feel
better after having a fit.
More recent research suggests that the effect is due to the fit
rather than the electrical current.
Q How often is it used?
It is now used less often. Between 1985 and 2002, its use in
England more than halved, possibly because of better psychological
and drug treatments for depression.
Q How does ECT work?
No-one is certain how ECT works. We do know that it can change
patterns of blood flow through the brain and change the metabolism
of areas of the brain which may be affected by depression. There is
evidence that severe depression is caused by problems with certain
brain chemicals. It is thought that ECT causes the release of these
chemicals and, probably more importantly, makes the chemicals more
likely to work and so help recovery.
Recent research has also suggested that ECT can help the growth
of new cells and nerve pathways in certain areas of the brain.
Q Does ECT really work?
It has been suggested that ECT works not because of the fit, but
because of all the other things – like the extra attention, support
and the anaesthetic – that happen to someone who has it.
Several studies have compared standard ECT with "sham" or
placebo ECT. In placebo ECT, the patient has exactly the same
things done to them – including going to the ECT rooms and having
the anaesthetic and muscle relaxant – but no electrical current is
passed and there is no fit. In these studies, the patients who had
standard ECT were much more likely to recover, and did so more
quickly than those who had the placebo treatment. Those who didn't
have adequate fits did less well than those who did. Some of the
patients who had "sham" treatment recovered too, even though they
were very unwell; it's clear that the extra support does help.
However, ECT has been shown to have an extra effect in severe
depression – it seems, in the short term, to be more helpful than
Pros & Cons of ECT
Q Who is ECT likely to help?
Someone who has severe depression, resistant mania or catatonia.
ECT should be considered for the rapid treatment of severe
depression that is life-threatening, or when other treatments have
It should not be used routinely in moderate depression. It can
be helpful for someone with moderate depression if they have not
responded to several different drug treatments and psychological
Q Who is ECT unlikely to help?
ECT is unlikely to help someone with mild to moderate depression
or most other psychiatric conditions. It is not used in
Q Why is it given when there are other treatments
ECT has been shown to be the most effective treatment for severe
depression. It would normally be offered if:
- several different medications have been tried, but have not
- the side-effects of antidepressants are too severe
- you have found ECT helpful in the past
- your life is in danger because you are not eating or drinking
- you are seriously considering suicide.
Q What are the side-effects of ECT?
ECT involves several treatments spread over a few weeks. As with
any treatment, ECT can cause a number of side-effects. Some of
these are mild and some are more severe.
Immediately after ECT, many people have a headache and some
aching in their muscles. They may feel muzzy-headed and generally
out of sorts, or even a bit sick. Some become distressed after the
treatment and may be tearful or frightened during recovery. For
most people, however, these effects settle within a few hours,
particularly with help and support from nursing staff, simple pain
killers and some light refreshment.
There may be some temporary loss of memory for the time
immediately before and after the ECT.
An older person may be confused for two or three hours after a
treatment. This can be reduced by changing the way the ECT is given
(such as passing the current over only one side of the brain rather
than across the whole brain).
ECT causes contraction of the jaw muscles. Although the ECT Team
will do all they can to minimise the risks, there remains a small
chance of damage to the tongue, teeth and lips. There are
particular risks where the teeth are less strong: for example if
you have crowns, veneers, or implants, also bridges and partial
dentures. Please let the team know have had cosmetic dental work or
There is a small physical risk from having a general anaesthetic
– death or serious injury occurs in about 1 in 80,000 treatments,
about the same as if you have an anaesthetic for dental treatment.
However, as ECT is given in a course of treatments, the risk per
course of treatment will be around 1 in 10 000.
Memory problems can be a longer-term side effect. Surveys
conducted by doctors and clinical staff usually find a low level of
severe side-effects, maybe around 1 in 10. Patient-led surveys have
found much more, maybe in half of those having ECT. Some surveys
conducted by those strongly against ECT say there are severe
side-effects in everyone.
Some memory problems are probably present in everyone receiving
ECT. Most people feel better after the course of ECT has finished
and a few weeks have passed. However, some people do complain that
their memory has been permanently affected, that their memories
never come back. It is not clear how much of this is due to the
ECT, and how much is due to the depressive illness or other
Some people have complained of more distressing experiences,
such as feeling that their personalities have changed, that they
have lost skills or that they are no longer the person they were
before ECT. They say that they have never got over the experience
and feel permanently harmed.
What seems to be generally agreed is that the more ECT someone
is given, the more it is likely to affect their memory.
Q What if ECT is not given?
- You may take longer to recover.
- If you are very depressed and are not eating or drinking
enough, you may become physically ill or die.
- There is an increased risk of suicide if your depression is
severe and has not been helped by other treatments.
Q What about driving?
Most people who are ill enough to require to ECT will be unfit
to drive. After a course of ECT you should discuss with your doctor
when you are well enough to resume driving. Sometimes
disorientation and impaired visual functioning may go on for
several months after ECT.
Q What are the alternatives?
- If someone with severe depression refuses ECT, the doctors can
try a different medication, or combination of medications
- Offer intensive psychotherapy, although this will usually have
already have been tried.
Given time, some episodes of severe depression will get better
on their own, although being severely depressed carries a real risk
of death by suicide.
Deciding to have (or not to have) ECT
Q Giving consent to having ECT
Like any significant treatment in medicine or surgery, you will
be asked to give consent, or permission for the ECT to be done.
The doctor should explain (in a way that you can understand)
their reasons for suggesting ECT, the possible benefits and any
side-effects. If you decide to go ahead, you then sign a consent
form. It is a record that ECT has been explained to you, that you
understand what is going to happen, and that you give your consent
to it. However, you can withdraw your consent at any point, even
before the first treatment.
Q What if I really don’t want ECT?
If you have very strong feelings about ECT, you should tell the
doctors and nurses caring for you, but also friends, family or an
advocate who can speak for you.
Doctors must consider your views when deciding what to do.
If you have made it clear that you do not want to have ECT, then
you should not be given it, except in special circumstances (see
below). You could write an 'advance statement' to refuse ECT if you
become unwell again. Alternatively, you could appoint someone to be
your Health and Welfare Attorney to make decisions on your behalf
when you are not able to decide for yourself.
Q Can ECT be given to me without my
Most ECT treatments are given to people who have agreed to it.
This means that they have had:
- a full discussion of what ECT involves
- why it is being considered in their case
- the advantages and disadvantages
- a discussion of side-effects.
You cannot usually be given ECT against your wishes, even if you
sectioned under the Mental Health Act. It is the responsibility
of the doctors and nurses involved to make sure that they have
discussed this with you – and to document it.
Sometimes, you can become so unwell that you can't understand
the information about ECT – if you are very withdrawn or have ideas
that stop you from understanding your position (e.g you believe
that your depression is a punishment you deserve).
In this situation, it may be impossible to give proper agreement
or consent. When this happens, it is still possible to give ECT.
The legal provisions for this differ from country to country, even
within the United Kingdom.
Mental Health Act
In England and Wales, ECT can be given under the Mental
Health Act. This means that two doctors and another
professional, who is usually a social worker, need to agree that
ECT should be given.
There must then be a second opinion from an independent
specialist who is not directly involved in the person's care. The
clinical team should also speak to family and other carers, to find
out what they think about ECT, but also to find out if the patient
had any opinion about it.
Mental Capacity Act
Sometimes - if a person doesn't have the capacity to give an
informed consent - the team may decide the ECT can be given under
Capacity Act. This is unusual, as in most cases, the Mental
Health Act provides the best protection for a patient's rights. The
Mental Capacity Act can only be used if the patient lacks capacity
and a "decision maker" (usually the consultant in charge of their
care) decides that ECT is in the patient's "best interests".
It is expected the decision maker will ask other people to try
to find out what the person's views would have been. This would
usually include family members and other people close to them. The
decision maker should also make "all reasonable attempts" to help
the patient to regain capacity to consent (if this is possible). An
independent specialist is not needed, though the clinical team may
request a second opinion from another consultant.
Whether ECT is given under the Mental Health Act or the Mental
Capacity Act, the team must make regular assessments of the
patient's ability to understand their treatment. Once the patient
is able to give consent, the treatment can only continue if they do
consent and must stop if they refuse.
In Scotland, the principles above are the same, although the
laws involved are the Mental Heath
(Care and Treatment) (Scotland) Act 2003 and the Adults
With Incapacity Act (Scotland) 2000.
Where is ECT given?
ECT is always given in hospital. As it is generally used in
severe depression, you would usually need to stay in hospital. Some
people do have ECT as a day patient, but you may need to check if
your local service can do this.
How is ECT given?
The seizure is brought on by passing an electrical current
across the brain in a carefully controlled way from a special ECT
- an anaesthetic and muscle relaxant are given so that you are
not conscious when the ECT is given.
- the muscle spasms that would normally be part of a fit – and
which could produce serious injuries - are reduced to small,
rhythmic movements in the arms, legs and body.
By adjusting the dose of electricity, the ECT team will try to
produce a seizure lasting between 20 and 50 seconds.
Q Is there any preparation?
In the days before you start a course of ECT, your doctor will
arrange for you to have some tests to make sure it is safe for you
to have a general anaesthetic. These may include:
- a chest X-ray
- a tracing of your heart working (ECG)
- blood tests.
You will be asked not to have anything to eat or drink for 6
hours before the ECT. This is so that the anaesthetic can be given
Q Where is ECT done?
ECT should always be done in a special set of rooms that are not
used for any other purpose, usually called the “ECT suite”. This
should be a separate area where you wait, have your treatment, wake
up fully from the anaesthetic and then recover properly before
There should be enough qualified staff to look after you while
you are there so that they can help you through any confusion or
Q What happens during ECT?
- You should arrive at the ECT suite with an experienced nurse
who you know and who is able to explain what is happening. Many ECT
suites are happy for family members to be there - you may want to
check with your local team that this is possible. You should be met
by a member of the ECT staff who will do routine physical checks,
if they have not already been done. They will check that you are
still willing to have ECT and if you have any further
- When you are ready you will be accompanied into the treatment
area and be helped onto a trolley.
- The ECT team will connect monitoring equipment to check your
heart rate, blood pressure, oxygen levels, ECG and EEG during the
- The anaesthetist will give you the anaesthetic through a needle
in your hand. Once you are asleep, they will give a muscle relaxant
through the same needle. While you are going off to sleep, the
anaesthetist will also give you oxygen to breathe.
- Once you are asleep and fully relaxed, a doctor will give the
ECT treatment. Your fit will last between around 20 to 50 seconds.
The muscle relaxant wears off quickly (within a couple of minutes)
and, as soon as the anaesthetist is happy that you are waking up,
you will be taken through to the recovery area where an experienced
nurse will monitor you until you are fully awake.
- When you wake up, you will be in the recovery room with a
nurse. He or she will take your blood pressure and ask you simple
questions to check on how awake you are. There will be a small
monitor on your finger to measure the oxygen in your blood, and you
may wake up with an oxygen mask. You will probably take a while to
wake up and may not know quite where you are at first. You may feel
a bit sick. After half an hour or so, these effects should have
- Most ECT units have a “recovery” area for rest and light
refreshments. You can leave when the staff are happy that your
physical state is stable and you feel ready to do so. It usually
takes around half an hour, from start to finish.
Q. What are bilateral and unilateral ECT?
In bilateral ECT, the electrical current is passed across the
In unilateral ECT, the current is just passed across one side.
Both of them cause a seizure in the whole of the brain.
Bilateral ECT seems to work more quickly and
effectively and it's probably the most widely used in Britain;
however, there has been concern that it may cause more
Unilateral ECT is now used less. It had been
thought to cause less memory loss, but recent research has shown
that it is necessary to use larger doses of electricity to make it
as effective as bilateral ECT. If the dose of electricity is
increased to make it equally effective, the risks of memory loss
are as great as with bilateral ECT.
Sometimes ECT clinics will start a course of treatment with
bilateral ECT and switch to unilateral if the patient experiences
side-effects. Alternatively, they may start with unilateral and
switch to bilateral if the person isn't getting better.
You may wish to speak to the doctor who is suggesting ECT for
you to decide whether unilateral or bilateral ECT is best for
Q How often and many times is ECT given?
Most units give ECT twice per week, often on a Monday and
Thursday, or Tuesday and Friday. It is impossible to predict how
many treatments someone will need. However, in general, it will
take 2 or 3 treatments before you see any difference, and 4 to 5
treatments for noticeable improvement.
A course will on average be 6 to 8 treatments, although as many
as 12 may be needed, particularly if you have been depressed for a
long time. If, after 12 treatments, you feel no better, it is
unlikely that ECT is going to help and the course would usually
stop. A member of the mental health team should check after each
treatment to see how your are responding, and to check that you are
not getting troublesome side-effects. Your consultant should see
you after every two treatments. ECT should be stopped as soon as
you have made a recovery, or if you say you don't want to have it
Q What happens after a course of ECT?
Even when someone finds it effective, ECT is only a part of
recovering from depression. Like
antidepressants, it can help to ease problems so you are able
to look at why you became unwell. Hopefully you can then take steps
to continue your recovery, and perhaps find ways to make sure the
situation doesn’t happen again.
Psychotherapy and counselling can help and many people find
their own ways to help themselves. Certainly people who have ECT,
and then do not have other forms of help, are likely to quickly
become unwell again.
The ECT Controversy
There are many areas in which people disagree over ECT,
including whether it should even be done at all. People tend to
have very strong feelings about ECT, often based on their own
experiences. The main areas of disagreement are over whether it
works, how it works and what the side-effects are.
Q Why is ECT still being given?
ECT is now used much less and is mostly a treatment for severe
depression. This is almost certainly because modern treatments for
depression are much more effective than they were in the past.
These include psychotherapy (talking treatments), antidepressants
and other psychological and social supports.
Even so, depression can for some people still be very severe and
even life-threatening. The person may be barely able to talk,
reluctant (or unable) to eat, drink or look after themselves.
Occasionally a person may also develop strange ideas (delusions)
about themselves or others. If other treatments have not have
worked, it may be worth considering ECT. It is a safe and effective
treatment for severe depression.
Q What do patients think of ECT?
In 2003 researchers analysed all the work which had been done on
patients' experiences of ECT. They found that the proportion of
people who had had ECT and found it helpful ranged from 30% to 80%.
The researchers commented that studies reporting lower satisfaction
tended to have been conducted by patients, and those reporting
higher satisfaction were carried out by doctors. Between 30% and
50% of patients complained of difficulties with memory after
Q What do those in favour of ECT say?
Many doctors and nurses will say that they have seen ECT relieve
very severe depressive illnesses when other treatments have failed.
Bearing in mind that 15% of people with severe depression will kill
themselves, they feel that ECT has saved patients' lives, and
therefore the overall benefits are greater than the risks. Some
people who have had ECT will agree, and may even ask for it if they
find themselves becoming depressed again.
Q What do those against ECT say?
There are different views and reasons why people object to ECT.
Some see ECT as a treatment that belongs to the past. They say that
the side-effects are severe and that psychiatrists have, either
accidentally or deliberately, ignored how severe they can be. They
say that ECT permanently damages both the brain and the mind, and
if it does work at all, does so in a way that is ultimately harmful
for the patient. Some would want to see it banned.
Q What happens in other countries?
At the moment, ECT is part of standard psychiatric practice in
Britain and the majority of countries worldwide. Some countries
(and some states in America also) have restricted its use more than
in the UK, though only a few have prohibited its use.
Q How do I know if ECT is done properly
The Royal College of Psychiatrists has set up the
ECT Accreditation Service (ECTAS) to provide an independent
assessment of the quality of ECT services. ECTAS sets very high
standards for ECT, and visits all the ECT units who have registered
with it. The visiting team involves psychiatrists, anaesthetists,
and nurses. It publishes the results of its findings and also
provides a forum for sharing best clinical practice. Membership of
ECTAS is not compulsory, but every ECT unit should be able to tell
- if they have signed up to ECTAS;
- the result of their most recent report;
- who to speak to if you are concerned that your local unit has
not been assessed.
A list of accredited site is available on the
Royal College of Psychiatrists'
Q Where can I get more information?
Many ECT suites provide their own information packs. They should
be able to give written information to you or your
National Institute for Health and Clinical Excellence
Scottish ECT Accreditation Network (SEAN): A site
designed to complement the work of SEAN, by enabling communication
of the latest information on ECT in Scotland.
Electroconvulsive Therapy Accreditation Services
(ECTAS): Launched in May 2003, ECTAS aims to assure
and improve the quality of the administration of ECT; awards an
accreditation rating to clinics that meet essential standard.
Ebmeier, K. et al (2006) Recent development and current
controversies in depression. Lancet, 367,153-167.
Eranti,S. V. & McLoughlin, D.M (2003) Electroconvulsive
therapy - state of the art. the British Journal of Psychiatry 182:
Perrin, J.S., Merz, S., Bennett, D.M. et al (2012)
Electroconvulsive therapy reduces frontal connectivity in severe
depressive disorder. Proceedings of the National Academy of
Sciences, 109, 5464-5468.
Rose, D., Fleischmann, P., Wykes, T., Leese, M. & Bindman,
J. (2003) Patients' perspectives on electroconvulsive therapy:
systematic review BMJ 2003;326;1363-1368.
The ECT Handbook (3rd edition): The Royal College of Psychiatrists’
Special Committee on ECT. Royal College of Psychiatrists
London UK ECT Review Group (2003).
Efficacy and safety of electroconvulsive therapy in depressive
disorders: a systematic review and meta-analysis. Lancet 361:
Department of Health Statistical survey (2007) Electro Convulsive
Therapy: Survey covering the period from January 2002 to March
2002, England. DH: London.
A list of accredited facilities is available on the
Royal College of Psychiatrists' website.
This leaflet was produced by the Royal College of Psychiatrists'
Special Committee on ECT and related treatments and Public
Engagement Editorial Board.
Series: Dr Philip Timms
Original author: Dr Richard Barnes
This leaflet reflects the best available evidence available at
the time of writing.
© April 2014. Due for review: April 2016. Royal College of
Psychiatrists. This leaflet may be downloaded, printed out,
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