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When discussing ECT, acknowledge patients fears but be ready to dispel myths around it. This is an area where you should be armed with statistics on benefits and risks. It is helpful to observe ECT during your training so that you can explain the process in detail to patients.
Key Knowledge
What is ECT?
Electricoconvulsive therapy (ECT) is a procedure performed under general anesthetic whereby electrical currents are passed through the brain to cause a brief, controlled seizure. The patient is fully asleep and a muscle relaxant is used. The procedure itself only lasts a few minutes, but the whole process is about one hour. Typically a patient has 6-12 treatments over 3-6 weeks, as the effect gradually builds with each treatment. The patient is supported by a psychiatrist, anesthetist and specialist nurses before, during and after the procedure.
How does ECT work?
This is not fully understood, but various mechanisms have been theorised, including alterations in neuroplasticity, neuroendocrine function, levels of neurotransmitters, and epigenetic processes [1]. One NHS organisation, describing this for patients, explains that ECT causes the release of brain chemicals, which lead to growth in certain brain areas [2].
What are the Indications for ECT?
The indications are:
● Severe depression (Nice Guideline NG222) if:
– the person chooses ECT in preference to other treatments based on their past experience of ECT and what has previously worked for them or
– a rapid response is needed (for example, if the depression is life‑threatening because the person is not eating or drinking) or
– other treatments have been unsuccessful
● Catatonia/severe psychosis (Nice Technology Appraisal Guideline TA59)
What are the Benefits of ECT?
According to current evidence:
● ECT can help people who are very unwell to get better enough to have other kinds of treatments. This can help them stay well for longer [5]
● Most people (~2/3rds), who have ECT see an improvement in their symptoms, only 1% report their condition was worse [5]
● For people with severe depression who get better after having ECT, half will stay better for at least 1 year (in comparison, only 5% of people with severe depression will get better and stay well for a year on third-line antidepressants) [5]
● For severe depression, it is more effective than placebo, antidepressants and neuromodulation such as Transcranial Magnetic Stimulation [5]
● ECT has been shown to lower suicide risk [5]
What are the Risks and Harms of ECT?
Memory problems
● This is the main concern with ECT, however it is difficult to separate the effect of ECT from the effect of depression on memory
● 1/5th of people report memory problems causing difficulties before ECT [5]
● 2/5ths of patients can have temporary memory problems while they are having ECT. For example, they may forget conversations with visitors during this time [5]
● For most people, memory difficulties clear within two months of the last treatment and do not cause problems [5]
● A small number of patients report gaps in their memory about events that happened in their life before ECT. Sometimes these return, but sometimes the gaps are permanent. About 7% of people receiving one-sided ECT report some persistent memory loss after 12-months [5]
Risks of anaesthesia
● Like all procedures under anaesthetic there is a risk of death.
● People admitted to hospital because of depression are less likely to die after having ECT than if they do not have ECT. This may be because ECT helps people recover from severe depression [5]
Other short term side effects
● Headaches
● Muscle / jaw ache
● Tiredness due to anaesthetic effects
● Temporary confusion, particularly in the elderly.
● Vomiting or nausea [5]
Communication Tips
● Acknowledge people’s concerns, e.g. “We know that ECT seems like a frightening type of treatment”
● Address misconceptions directly, e.g. “Modern ECT is very different from what you might have seen in TV and films – patients are asleep, feel no pain, and are closely monitored throughout.”
● “Chunk and check” – explain in short sections, pause to check understanding and invite questions.
● Address memory concerns, e.g. “Most memory problems are short-lived, but a small number of people can have persistent gaps in memories for past events. This is less than 10%. However, it is something we have to consider when weighing up the decision to use ECT treatment.”
● Clearly explain rationale, e.g. “We recommend ECT when we consider the risks of untreated depression to be higher than any risks from treatment. In some cases, ECT can be a life-saving treatment” or “Other options have not worked, and your father’s life is at risk. ECT offers the best chance for him to start eating and drinking again”
CASC Practice Scenarios
Scenario 1: History Taking
Candidate Instructions
You are working on an older adult inpatient psychiatric ward. Mr. Alan Crow, a 70-year-old retired architect, has been admitted with severe psychotic depression. He has not improved after trials of two antidepressants, lithium augmentation, and antipsychotic medication. His mental state is deteriorating: he has stopped eating and drinking, and is now mute and largely immobile, with rising concerns about dehydration and physical health.
The consultant has recommended electroconvulsive therapy (ECT). Mr. Crow lacks capacity to consent. His son, David Crow, has asked to speak with you, as he is worried about the proposed plan.
Speak to Mr. Crow’s son to explore his concerns.
Actor Instructions
You are David Crow, son of Alan Crow. You are very worried about your father, who has become withdrawn and unresponsive. You know he has struggled with depression before, but you have never seen him this unwell. You are shocked to hear that ECT is being considered – you thought it was an old, discredited treatment.
You are concerned ECT will be painful, could harm his memory, or might even be dangerous given his age and frailty.
You want to know why it is being recommended, what the procedure involves, what risks there are, and if there are any other options. You want to do what is best for your father and are open to honest discussion.
If you feel listened to, you will share that you are especially worried about long-term memory loss and whether your father will ever forgive you for agreeing to ECT. You want reassurance that everything possible is being done to keep him safe.
Feedback for Scenario 1
Knowledge & Clinical Skills
A good candidate will:
● Explain why ECT is recommended in this case (including failure of numerous treatment lines) and its role as a rapid, effective treatment in life-threatening severe depression
● Describe how modern ECT is administered, explaining the basics of inducing a brief seizure, and the nature of treatment as a course not a one off
● Describe the multidisciplinary team involved in supporting a patient through ECT treatment
● Provide balanced information about side effects, backed up by facts.
● Explain that while other treatments exist, evidence suggests they are less effective
Communication
A good candidate will:
● Listen to David’s concerns
● Use clear language without jargon
● Chunk and check
● Acknowledge the difficulty of making a decision on behalf of someone who lacks capacity, but highlight evidence base for ECT in this scenario and inclusion in NICE guidelines
● Provide reassurance about safety whilst acknowledging risks like any medical procedure
Example phrases:
“I understand this treatment sounds frightening and that you’re worried about your father’s memory and safety.”
“Would you like me to explain that part again? Do you have any questions?”
“We are in a difficult situation, as your father is very unwell and can’t make decisions for himself. We have to weigh up the risks ECT treatment against an alternative treatment, which may be less effective. In this situation, treating your father with ECT would be in-line with national guidelines and in his best interest.”
Scenario 1: Example Video
Candidate Instructions:
You are asked to meet with Ms. Georgia Ellis. Her mother, Mrs. Jill Ellis, a 63-year-old woman with severe psychotic depression, has not improved despite multiple courses of antidepressants, antipsychotics, and lithium. Due to refusal of food and fluid, life-threatening risk, and depressed stupor, the consultant recommends urgent ECT. Georgia is upset and wants more information.
Explore her concerns and explain the rationale, risks, and alternatives to ECT.
Authors / Reviewers
Dr Damir Rafi is a psychiatry speciality registrar in forensics, currently working in London.
Dr Sarah Barber is a Psychiatry Registrar, currently taking time out of clinical work to complete a PhD in psychiatric epidemiology.
References and Resources
1. Singh, A. and Kar, S.K., 2017. How electroconvulsive therapy works?: understanding the neurobiological mechanisms. Clinical Psychopharmacology and Neuroscience, 15(3), p.210.
2. How does ECT Work?: Interventional Psychiatry Service, Oxford Health NHS Foundation Trust. Retrieved from https://www.oxfordhealth.nhs.uk/ips/ect/how-does-ect-work/
3. National Institute for Health and Care Excellence (NICE). (2022). Depression in adults: treatment and management NICE guideline [NG22]. Retrieved from https://www.nice.org.uk/guidance/ng222
4. National Institute for Health and Care Excellence (NICE). (2009). Guidance on the use of electroconvulsive therapy. Technology appraisal guidance [TA59]. Retrieved from https://www.nice.org.uk/guidance/ta5
5. Royal College of Psychiatrists (2024) Electroconvulsive therapy (ECT): Patient Information. Accessed from https://www.rcpsych.ac.uk/mental-health/treatments-and-wellbeing/ect on 23/09/25; [used for data on benefits and risks of ECT]
Disclaimer:
This article is intended for use as a learning resource for doctors training in Psychiatry in the UK. It is not intended for patients. If you are looking for information about mental health conditions, please visit www.rcpsych.ac.uk/mental-health to find readable, user-friendly and evidence-based information on mental health problems, treatments and other topics written by qualified psychiatrists, with help from patients and carers. If you are looking for help for a mental health condition, please visit https://www.mind.org.uk/ for information about where help is available.
The article was written by UK doctors and cross-checked against various published sources (see Reference list). We endeavour to keep information up to date, but it should not be relied on for clinical decision making. Consult local guidelines and senior colleagues whenever you are not sure.