ECT (Electro-convulsive therapy)
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
Although a safe and effective treatment, ECT
remains controversial and we have included some of the different
views about it.
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
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
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
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
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 failed.
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
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 schizophrenia.
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
- several different medications have been
tried, but have not helped
- the side-effects of antidepressants are too
- you have found ECT helpful in the past
- your life is in danger because you are not
eating or drinking enough
- 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 piercings undertaken.
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
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 factors.
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
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
- There is an increased risk of suicide if
your depression is severe and has not been helped by other
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
- Offer intensive
psychotherapy, although this will usually have already have
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
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
- the advantages and disadvantages
- a discussion of side-effects.
You cannot usually be given ECT against your
wishes, even if you are
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
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
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 the Mental
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
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 machine.
- 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
By adjusting the dose of electricity, the
ECT team will try to produce a seizure lasting between 20 and 50
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
- 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 safely.
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 leaving.
There should be enough qualified staff to
look after you while you are there so that they can help you
through any confusion or distress.
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
- 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 fit.
- 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
- 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 worn off.
- 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
Q. What are bilateral and unilateral ECT?
In bilateral ECT, the electrical current is
passed across the whole brain
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 side-effects.
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
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
You may wish to speak to the doctor who is
suggesting ECT for you to decide whether unilateral or bilateral
ECT is best for you.
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 any more.
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 ECT.
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
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
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
- who to speak to if you are concerned that
your local unit has not been assessed.
A list of accredited site is available on
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 family/carers.
National Institute for Health and
Clinical Excellence (NICE)
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: 8-9.
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
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.
This leaflet was produced by the Royal College of
Psychiatrists' Special Committee on ECT and related treatments and
Public Education 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.
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