Electroconvulsive Therapy (ECT): How It Works, Cost, & What to Expect

What Is ECT?

Electroconvulsive therapy is an approved and regulated mental health treatment for people with psychological issues that are not well-managed with other interventions. ECT uses electrical current to “rewire” the brain in a safe and comfortable way. The patient typically undergoes general anesthesia for the procedure, so they are asleep during the entire ECT process.^1,2

ECT, sometimes called shock therapy, shock treatment, or electroshock therapy, has come a long way in recent decades to address the negative perceptions of the procedure. Instead of using large amounts of electricity without anesthesia, today’s ECT produces positive results for most who undergo the treatment.² By connecting the patient to a controlled electrical current, ECT produces a brief seizure in order to adjust their brain activity.

Though ECT may seem controversial due to its unique method of action, major medical and mental health organizations endorse the use of ECT. The American Psychiatric Association, the National Institute on Mental Health, and the American Medical Association all recognize ECT as a valid treatment. Many organizations around the world similarly approve of ECT.⁴

What Can Electroconvulsive Therapy Help With?

This process can help reduce signs and symptoms of various mental health conditions. Often, ECT is used as a last resort after other treatments for depression and medications for depression have been ineffective, but the treatment may be the primary course of action in certain situations where speed of results is key.³

Experts continue to test and expand upon the uses of ECT for a variety of other mental health conditions as well.

Currently, electroconvulsive therapy is used to treat:^2,4

• Severe depression, especially in cases of suicidality
• Treatment-resistant depression—depressive symptoms that have not responded to the standard battery of therapy and medications
• Schizophrenia, especially when the person presents as being very disconnected from society with disorganized thoughts or actions
• Bipolar disorder, especially when manic symptoms are prevalent and healthy decision making is replaced by impulsivity and risky behaviors
• Catatonia—a symptom of depression or schizophrenia where a person could be unresponsive to outside communication or stimulation
• Dementia, when the person tends to become agitated, violent, and aggressive

Unable to Take Medication

Some people are good candidates for ECT if they are unable to use psychiatric medications. Those with allergies or very significant side effects may consider ECT to help manage their unwanted symptoms.¹

As a Treatment During Pregnancy

Other people will consider ECT when pregnant. For a person who is at great risk of mental health complications but cannot use medications due to pregnancy, ECT could be the best option. As always, this person must have a conversation with the treatment team regarding pregnancy and the possible effects of ECT on the fetus.²

Who Is ECT Not Recommended For?

ECT is not the best fit for everyone. For people who are elderly or have certain medical conditions, such as heart problems, ECT poses significant risks and should not be used. Similarly, those who are unable to undergo general anesthesia or use muscle relaxants also should not engage in ECT. Children also may not receive ECT treatment in most cases. ECT is also not a first-line treatment for any mental health condition, and should only be implemented after careful consideration, once therapy and medication have been tried unsuccessfully.

Does ECT Work?

ECT is very effective, but the treatment may not be equally effective for all symptoms and situations. Overall, for a certain subset of people who cannot use psychiatric medications or have mental health conditions like chronic depression, intense bipolar disorder, or schizophrenia, ECT is a valid treatment option worthy of consideration.

Electroconvulsive Therapy for Clinical Depression

Some of the best evidence for ECT shows the procedure creates “substantial improvement” in 80% of patients with severe depression.⁴ Similar effects may be achieved in people with other conditions after undergoing ECT.³

Even better than the high success rates is the speed at which ECT produces these results. Patients may begin to notice changes to their mental health in as few as six sessions, which could be less than two weeks. Often, antidepressant medications can take four to six weeks to begin showing positive effects.²

ECT can help people experience a total alleviation of depressive symptoms. Studies show that about 75% of people note a remission of depressive symptoms, compared to about 35% of people who use medication only.⁶ These rates are similar for bipolar disorder as well.

What Are the Risks & Side Effects of ECT?

The biggest risks associated with ECT are the side effects that may follow treatment. Though the risks tend to be mild and almost never life-threatening, they can still deter some people from attending the treatment.

Some of the most significant risks of ECT stem from the anesthesia, rather than the actual treatment. People who have negative experiences with anesthesia should be sure to discuss the concerns with their treatment providers.²

The risks of ECT continue to decrease as the treatment evolves. In the 1990s, the mortality rate of ECT was as high as 10 per 100,000, but by the 2010s, the rate fell to less than 1 per 100,000.⁶

Side Effects of Electroconvulsive Therapy

Like other treatments for mental health conditions, electroconvulsive therapy may lead to side effects for some patients. A combination of mental health and physical health side effects are possible, and even though they may be uncomfortable or concerning, they are usually better than the risks of severe depression.

Common side effects of electroconvulsive therapy include:^1,2

• Confusion
• Headache
• Jaw pain
• Changes in blood pressure
• Memory loss
• Muscle soreness
• Nausea
• Quicker heart rate (tachycardia)

As the safety of ECT improves, the side effects become more mild and sporadic. In the past, memory loss was much more common, but now, people experiencing permanent loss of memory from ECT is rarer.¹

Benefits of ECT

ECT has many benefits for those with more severe mental health disorders like treatment-resistant depression, and is supported by current research.

Here are some of the benefits of ECT:

• It’s effective: Research has shown that ECT is effective in decreasing the risk of suicide and hospitalization, and improving quality of life.⁸
• It’s safe: Studies have demonstrated ECT’s safety, with no significant safety risks for adults.⁹
• It can help when other treatments aren’t working: ECT is often helpful when other treatments are not successful, providing hope for severe and persistent mental health disorders.
• It can be especially effective when combined with medication: ECT can be a lifesaving treatment, and is often utilized in conjunction with medication.¹⁰
• It works quickly: While it can take up to four weeks for antidepressants to take effect, ECT can begin working immediately.

What to Expect During ECT

Even though ECT is used to help with mental health concerns, the process may feel more like a medical procedure. In many cases, providers perform the treatment in an acute care hospital under the supervision of medical and mental health professionals. ECT is administered by a team of medical professionals, typically directed by a psychiatrist. An anesthesiologist will also be present to administer medications.⁴

Before the Procedure

Several essential elements of ECT occur well before the actual treatment. First, the person will need a full psychiatric and medical assessment. Because ECT involves passing electricity through the brain, providers need to ensure the patient is a good candidate for ECT. Doctors may perform blood work and a heart test called an electrocardiogram to ensure the heart is healthy enough for the procedure.⁴

Next, the patient must provide their informed consent. This consent essentially gives permission to the providers to complete the ECT treatment. In some situations, the person may be too impaired to actively provide consent, so a guardian or court-appointed individual could make the decision on the patient’s behalf.⁴ Once the person passes the assessment and provides consent, the procedure can be scheduled.

During the Procedure

As part of ECT, the patient will:^1,2,4

• Have an IV line inserted: In the hand or arm, a medical professional will add an IV, so medications and fluids can be given quickly.
• Be put to sleep with general anesthesia and muscle relaxants: The anesthesia will induce a sleeping state, and the muscle relaxants will help keep the body calm and still during the procedure.
• Have electrodes placed on their head: These electrodes will be placed with precision to produce the best results. Two electrodes will monitor brain activity, and two others will deliver the electrical current.
• Receive the electric stimulation and have a seizure: The electrical current passes through the brain for about 40 seconds, which triggers the seizure. Because of the medications used, the seizure does not spread throughout the body. In fact, the person’s hands and legs will only twitch slightly.
• Wake up in a recovery room: After the procedure, the person is moved from the treatment room to a place to recover. Staff will monitor their vital signs. The person will have no recollection of the process.
• Leave the treatment center or return to their room: If the ECT is completed as an outpatient treatment, someone will drive the patient home. If the person is currently completing an inpatient stay, they will return to their room.

What Happens Right After the Procedure?

After an ECT treatment, the medical team will observe the client’s vital signs and transfer them to a recovery room. There, the client can sleep for 30 – 60 minutes. They may experience confusion upon waking, which can last anywhere from a few minutes to several hours. The medical staff work with the client to reassure and reorient them during this brief period, while continuing to monitor for any complications, before releasing them. Another adult must be present to drive the client home, and after-care instructions are provided.¹¹

What Is the Recovery Time?

Most people receive three ECT treatments per week for several weeks. After treatment concludes, it may take several weeks to fully recover from the course of ECT treatment, particularly in regards to the ability to learn and remember new information. Most clients will begin to experience symptom relief after about six treatments, and a full course of ECT treatment is necessary for full improvement.¹³

How Many Times Will I Go?

ECT treatment is completed in a series of sessions. Providers will schedule 6-12 treatments that are 2-5 days apart. The total duration for a course of ECT could last between two weeks and two months.¹ At times, people will need multiple courses of treatment over time to receive the full benefit or maintain their previous results.⁴

With ECT, there is a potential that a client would need another round of sessions later on. Months or years could go by before their psychiatrist recommends the treatment again.

Coordination of Care

Depending on the area and treatment providers involved, the coordination of care during ECT will be essential. People providing the ECT may not offer other psychiatric or therapy services, so psychiatrists, prescribers, therapists, case managers, and the patient should all work to communicate frequently to ensure a consistent continuum of care.

Electroconvulsive Therapy Cost

Because ECT is a medical procedure that requires the time, space, and resources of several medical professionals, the treatment is expensive—especially when compared to medication or therapy services. One ECT treatment can cost as much as $1,000, while a year of antidepressant medication can cost just a few hundred dollars.⁷

Even though ECT may seem expensive, there are two important considerations:^4,7

• Many insurance companies will pay for all or some of ECT treatment.
• ECT is cost effective when balanced against the cost of being severely depressed with missing work and needing intensive treatment.

Can Depression Return If You Stop Treatment?

While ECT offers fast, effective relief from symptoms of severe depression, it does not guarantee that the depression will not return. Maintenance treatment is important in order to prevent a recurrence. This may include occasional ECT treatments, but most often involves medication and therapy.(FN12)

History of ECT

The principles of ECT date back to the 1930s when neuropsychiatrists and neurologists explored the relationships between seizure activity and mental health issues. In 1938, Ugo Cerletti first used electricity as a way to trigger a seizure.⁶

With evidence of significant improvements in patients, ECT gained wide acceptance in the 1940s and 1950 and was used on the most symptomatic people in mental institutions. This version of ECT involved no anesthesia and higher doses of electricity for long periods, resulting in many ill effects like personality changes, memory loss, bone breaks, joint dislocations, and dental injuries.⁶

In the 1960s and 1970s, ECT began shifting with the addition of anesthesia and more rigorous efforts to obtain and standardize consent. This way, a patient would better understand what ECT involved and could refuse the treatment.⁶

Starting in the 2000s, clinicians and researchers took new measures to establish safe and consistent ECT procedures that focused on creating rapid improvements with limited side effects. Now, ECT stands as an excellent and established alternative to other mental health treatments.⁶

ECT vs. TMS

ECT is a unique treatment to address and improve symptoms related to depression, bipolar, and other health conditions, but it is not the only brain stimulation treatment. Transcranial magnetic stimulation (TMS) is quite different from ECT, but the treatments may look similar.

Like ECT, TMS stimulates the brain to address treatment-resistant depression. Unlike ECT, TMS uses magnetic fields rather than electricity to create change, and does not trigger a seizure. Since TMS has mild side effects, the treatment is offered four or five times per week for up to six weeks.⁴

ECT Vs. VNS

Vagus nerve stimulation (VNS) is another brain stimulation therapy used to treat neurological and psychiatric disorders, including depression. It differs from ECT in that it is an invasive approach that involves implanting a device under the skin of the chest that will send electrical impulses through the vagus nerve in the neck to the brain, aiming to stimulate certain areas of the brain that regulate mood. This approach is more costly and invasive, though it is considered to be safe with fewer side effects. Both are utilized in addressing treatment-resistant depression. Though ECT has a stronger evidence-base at this time, VNS has been proven to be promising adjunctive treatment for severe, persistent depression.¹⁴

How to Find an Electroconvulsive Therapy Provider

Because ECT is not as widely available as therapy or medication services, a person may have to do some research to find an ECT provider. There may not be a national directory of ECT providers, but someone interested in ECT can ask their primary care provider for a referral or a list of providers that offer ECT in their area.

What to Expect at Your First ECT Appointment

The first ECT appointment may feel intimidating or scary because the process is new. Ideally, the treatment staff will fully describe the treatment to reduce fears and encourage comfort. In most cases, the patient will remember very little of the ECT treatment. They will enter the treatment room, receive an IV, and fall asleep shortly after the staff administers the anesthesia. The patient may be awake for the electrode pads, a mouth guard, and an oxygen mask to be applied.²

Next thing they know, the person will be in the recovery room. They may feel disoriented and slightly confused. A loved one will drive them home, or they will return to their hospital room to continue the recovery process. It may take a few hours for the side effects of nausea, headache, and fatigue to pass.⁴