Electroconvulsive therapy (ECT), formerly known as electroshock therapy and often referred to as shock treatment, is a standard psychiatric treatment in which seizures are electrically induced in patients to provide relief from psychiatric illnesses.
A round of ECT is effective for about 50% of people with treatment-resistant major depressive disorder, whether it is unipolar or bipolar. Followup treatment is still poorly studied, but about half of people who respond relapse within twelve months.
Aside from effects in the brain, the general physical risks of ECT are similar to those of brief general anesthesia.:259 Immediately following treatment, the most common adverse effects are confusion and memory loss. ECT is considered one of the least harmful treatment options available for severely depressed pregnant women.
A usual course of ECT involves multiple administrations, typically given two or three times per week until the patient is no longer suffering symptoms. ECT is administered under anesthetic with a muscle relaxant. Electroconvulsive therapy can differ in its application in three ways: electrode placement, frequency of treatments, and the electrical waveform of the stimulus. These three forms of application have significant differences in both adverse side effects and symptom remission. After treatment, drug therapy is usually continued, and some patients receive maintenance ECT. Administration (in the UK) is most commonly bilateral, in which the electrical current is passed across the whole brain. This seems to have greater efficacy, but also carries greater risk of memory loss. Less commonly (in the UK), ECT is administered unilaterally, which is less successful in producing the desired result, but carries a lower risk of memory loss.
- 1 Medical use
- 2 Adverse effects
- 3 Mechanism of action
- 4 Usage
- 5 History
- 6 Society and culture
- 7 See also
- 8 References
- 9 External links
ECT is used with informed consent in treatment-resistant major depressive disorder, treatment-resistant catatonia, or prolonged or severe mania, and in conditions where "there is a need for rapid, definitive response because of the severity of a psychiatric or medical condition (e.g., when illness is characterized by stupor, marked psychomotor retardation, depressive delusions or hallucinations, or life–threatening physical exhaustion associated with mania)."
Major depressive disorder
For major depressive disorder, ECT is generally used only when other treatments have failed, or in emergencies, such as imminent suicide. ECT has also been used in selected cases of depression occurring in the setting of multiple sclerosis, Parkinson's disease, Huntington's chorea, developmental delay, brain arteriovenous malformations and hydrocephalus.
A meta-analysis done on the effectiveness of ECT in unipolar and bipolar depression was conducted in 2012. Findings showed that, although patients with unipolar depression and bipolar depression responded to other medical treatments very differently, both groups responded equally well to ECT. Overall remission rate for patients with unipolar depression to a round of ECT treatment was 51.5% and 50.9% in those with bipolar depression. The severity of each patient’s depression was assessed at the same baseline in each group.
There is little agreement on the most appropriate followup to ECT for people with major depressive disorder. When ECT is followed by treatment with antidepressants, about 50% of people relapsed by 12 months following successful initial treatment with ECT, with the about 37% relapsing within the first 6 months. About twice as many relapsed with no antidepressants. Most of the evidence for continuation therapy is with tricyclics; evidence for relapse prevention with newer antidepressants is lacking.
In 2008, a meta-analytic review paper found in terms of efficacy, "a significant superiority of ECT in all comparisons: ECT versus simulated ECT, ECT versus placebo, ECT versus antidepressants in general, ECT versus TCAs and ECT versus MAOIs."
In 2003, The UK ECT Review group published a systematic review and meta-analysis comparing ECT to placebo and antidepressant drugs. This meta-analysis demonstrated a large effect size (high efficacy relative to the mean in terms of the standard deviation) for ECT versus placebo, and versus antidepressant drugs.
Compared with transcranial magnetic stimulation for people with treatment-resistant major depressive disorder, ECT relieves depression about twice as well, reducing the score on the Hamilton Rating Scale for Depression by about 15 points, while TMS reduced it by 9 points.
ECT is generally a second-line treatment for people with catatonia who don't respond to other treatments, but is a first-line treatment for severe or life-threatening catatonia. There is a lack of clinical evidence for its efficacy but "the excellent efficacy of ECT in catatonia is generally acknowledged". For people with autism spectrum disorders who have catatonia, there is little published evidence about the efficacy of ECT; as of 2014 there were twelve case reports, and while ECT had "life saving" efficacy in some, results were mixed and temporary, and maintenance ECT was necessary to sustain any benefit.
ECT is used to treat people who have severe or prolonged mania;  NICE recommends it only in life-threatening situations or when other treatments have failed. and as a second-line treatment for bipolar mania.
ECT is rarely used in treatment-resistant schizophrenia, but is sometimes recommended for schizophrenia when short term global improvement is desired, or the subject shows little response to antipsychotics alone.
Whether psychiatric medications are terminated prior to treatment or maintained, varies.:1885 However, drugs that are known to cause toxicity in combination with ECT, such as lithium, are discontinued, and benzodiazepines, which increase seizure thresholds, are either discontinued, a benzodiazepine antagonist is administered at each ECT session, or the ECT treatment is adjusted accordingly.:1879:1875
The placement of electrodes, as well as the dose and duration of the stimulation is determined on a per-patient basis.:1881
In unilateral ECT, both electrodes are placed on the same side of the patient's head. Unilateral ECT may be used first to minimize side effects (memory loss). When electrodes are placed on both sides of the head, this is known as bilateral ECT. In bifrontal ECT, an uncommon variation, the electrode position is somewhere between bilateral and unilateral. Unilateral is thought to cause fewer cognitive effects than bilateral but is considered less effective if the dose administered is close to the seizure threshold.:1881 In the USA most patients receive bilateral ECT. In the UK almost all patients receive bilateral ECT.
The electrodes deliver an electrical stimulus. The stimulus levels recommended for ECT are in excess of an individual's seizure threshold: about one and a half times seizure threshold for bilateral ECT and up to 12 times for unilateral ECT.:1881 Below these levels treatment may not be effective in spite of a seizure, while doses massively above threshold level, especially with bilateral ECT, expose patients to the risk of more severe cognitive impairment without additional therapeutic gains. Seizure threshold is determined by trial and error ("dose titration"). Some psychiatrists use dose titration, some still use "fixed dose" (that is, all patients are given the same dose) and others compromise by roughly estimating a patient's threshold according to age and sex. Older men tend to have higher thresholds than younger women, but it is not a hard and fast rule, and other factors, for example drugs, affect seizure threshold.
Immediately prior to treatment, a patient is given a short-acting anesthetic such as methohexital, etomidate, or thiopental, a muscle relaxant such as suxamethonium (succinylcholine), and occasionally atropine to inhibit salivation.:1882 In a minority of countries such as Japan, India, and Nigeria, ECT may be used without anesthesia. The Union Health Ministry of India recommended a ban on ECT without anesthesia in India's Mental Health Care Bill of 2010 and the Mental Health Care Bill of 2013. Some psychiatrists in India argued against the ban on unmodified ECT due to a lack of trained anesthesiologists available to administer ECT with anesthesia. The practice was abolished in Turkey's largest psychiatric hospital in 2008.
The patient's EEG, ECG, and blood oxygen levels are monitored during treatment.:1882
ECT is usually administered three times a week, on alternate days, over a course of two to four weeks.:1882–1883
Most modern ECT devices deliver a brief-pulse current, which is thought to cause fewer cognitive effects than the sine-wave currents which were originally used in ECT. A small minority of psychiatrists in the USA still use sine-wave stimuli. Sine-wave is no longer used in the UK or Ireland. Typically, the electrical stimulus used in ECT is about 800 milliamps and has up to several hundred watts, and the current flows for between one and 6 seconds.
In the USA, ECT devices are manufactured by two companies, Somatics, which is owned by psychiatrists Richard Abrams and Conrad Swartz, and Mecta. In the UK, the market for ECT devices was long monopolized by Ectron Ltd, which was set up by psychiatrist Robert Russell.
Aside from effects in the brain, the general physical risks of ECT are similar to those of brief general anesthesia; the U.S. Surgeon General's report says that there are "no absolute health contraindications" to its use.:259 Immediately following treatment, the most common adverse effects are confusion and memory loss. It must be used very cautiously in people with epilepsy or other neurological disorders because by its nature it provokes small tonic-clonic seizures, and so would likely not be given to a person whose epilepsy is not well controlled. Some patients experience muscle soreness after ECT. This is due to the muscle relaxants given during the procedure and rarely due to muscle activity. ECT, especially if combined with deep sleep therapy, may lead to brain damage if administered in such a way as to lead to hypoxia or anoxia in the patient. The death rate due to ECT is around 4 per 100,000 procedures. There is evidence and rationale to support giving low doses of benzodiazepines or else low doses of general anesthetics which induce sedation but not anesthesia to patients to reduce adverse effects of ECT.
While there are no absolute contraindications for ECT, there is increased risk for patients who have unstable or severe cardiovascular conditions or aneurysms; who have recently had a stroke; who have increased intracranial pressure (for instance, due to a solid brain tumor), or who have severe pulmonary conditions, or who are generally at high risk for receiving anesthesia.:30
Effects on memory
Retrograde amnesia occurs to some extent in almost all ECT recipients. The American Psychiatric Association report (2001) acknowledges: “In some patients the recovery from retrograde amnesia will be incomplete, and evidence has shown that ECT can result in persistent or permanent memory loss”. It is the purported effects of ECT on long-term memory that give rise to much of the concern surrounding its use.
However, the methods used to measure memory loss are generally poor, and their application to people with depression, who have cognitive deficits including problems with memory, have been problematic.
The acute effects of ECT can include amnesia, both retrograde (for events occurring before the treatment) and anterograde (for events occurring after the treatment). Memory loss and confusion are more pronounced with bilateral electrode placement rather than unilateral, and with outdated sine-wave rather than brief-pulse currents. The use of either constant or pulsing electrical impulses also varied the memory loss results in patients. Patients who received pulsing electrical impulses as opposed to a steady flow seemed to incur less memory loss. The vast majority of modern treatment uses brief pulse currents.
Retrograde amnesia is most marked for events occurring in the weeks or months before treatment, with one study showing that although some people lose memories from years prior to treatment, recovery of such memories was "virtually complete" by seven months post-treatment, with the only enduring loss being memories in the weeks and months prior to the treatment. Anterograde memory loss is usually limited to the time of treatment itself or shortly afterwards. In the weeks and months following ECT these memory problems gradually improve, but some people have persistent losses, especially with bilateral ECT. One published review summarizing the results of questionnaires about subjective memory loss found that between 29% and 55% of respondents believed they experienced long-lasting or permanent memory changes. In 2000, American psychiatrist Sarah Lisanby and colleagues found that bilateral ECT left patients with more persistently impaired memory of public events as compared to RUL ECT.
Effects on brain structure
Considerable controversy exists over the effects of ECT on brain tissue, although a number of mental health associations — including the American Psychiatric Association — have concluded that there is no evidence that ECT causes structural brain damage. A 1999 report by the U.S. Surgeon General states, "The fears that ECT causes gross structural brain pathology have not been supported by decades of methodologically sound research in both humans and animals".
Many expert proponents of ECT maintain that the procedure is safe and does not cause brain damage. Dr. Charles Kellner, a prominent ECT researcher and former chief editor of the Journal of ECT, stated in a 2007 interview that, "There are a number of well-designed studies that show ECT does not cause brain damage and numerous reports of patients who have received a large number of treatments over their lifetime and have suffered no significant problems due to ECT." Dr. Kellner cites a study purporting to show an absence of cognitive impairment in eight subjects after more than 100 lifetime ECT treatments. Dr. Kellner stated "Rather than cause brain damage, there is evidence that ECT may reverse some of the damaging effects of serious psychiatric illness."
Effects in pregnancy
If steps are taken to decrease potential risks, ECT is generally accepted to be relatively safe during all trimesters of pregnancy, particularly when compared to pharmacological treatments. Suggested preparation for ECT during pregnancy includes a pelvic examination, discontinuation of nonessential anticholinergic medication, uterine tocodynamometry, intravenous hydration, and administration of a nonparticulate antacid. During ECT, elevation of the pregnant woman's right hip, external fetal cardiac monitoring, intubation, and avoidance of excessive hyperventilation are recommended.
Mechanism of action
Despite decades of research, the exact mechanism of action of ECT remains elusive. Neuroimaging studies in people who have had ECT, investigating differences between responders and nonresponders, and people who relapse, find that responders have anticonvulsant effects mostly in the frontal lobes, which corresponds to immediate responses, and neurotrophic effects primarily in the medial temporal lobe. The anticonvulsant effects are decreased blood flow and decreased metabolism, while the neurotrophic effects are opposite - increased perfusion and metabolism, as well as increased volume of the hippocampus.
As of 2001, it was estimated that about one million people received ECT annually.
There is wide variation in ECT use between different countries, different hospitals, and different psychiatrists. International practice varies considerably from widespread use of the therapy in many western countries to a small minority of countries that do not use ECT at all, such as Slovenia.
About 70 percent of ECT patients are women. This may be due to the fact that women are more likely to be diagnosed with depression. Older and more affluent patients are also more likely to receive ECT. The use of ECT is not as common in ethnic minorities.
Sarah Hall reports, "ECT has been dogged by conflict between psychiatrists who swear by it, and some patients and families of patients who say that their lives have been ruined by it. It is controversial in some European countries such as the Netherlands and Italy, where its use is severely restricted".
ECT became popular in the United States in the 1940s. At this time psychiatric hospitals were overrun with patients whom doctors were desperate to treat and cure. The practices of ECT and lobotomies became popular because they held some promise of addressing the overpopulation problem. Whereas lobotomies would reduce a patient to a more manageable submissive state ECT helped to improve mood in those with severe depression. In the United States, a survey of psychiatric practice in the late 1980s found that an estimated 100,000 people received ECT annually, with wide variation between metropolitan statistical areas. Accurate statistics about the frequency, context and circumstances of ECT in the United States are difficult to obtain because only a few states have reporting laws that require the treating facility to supply state authorities with this information. In 13 of the 50 states, the practice of ECT is regulated by law. One state which does report such data is Texas, where in the mid-1990s ECT was used in about one third of psychiatric facilities and given to about 1,650 people annually. Usage of ECT has since declined slightly; in 2000–01 ECT was given to about 1500 people aged from 16 to 97 (in Texas it is illegal to give ECT to anyone under sixteen). ECT is more commonly used in private psychiatric hospitals than in public hospitals, and minority patients are underrepresented in the ECT statistics. In the United States, ECT is usually given three times a week; in the UK, it is usually given twice a week. Occasionally it is given on a daily basis. A course usually consists of 6–12 treatments, but may be more or fewer. Following a course of ECT some patients may be given continuation or maintenance ECT with further treatments at weekly, fortnightly or monthly intervals. A few psychiatrists in the USA use multiple-monitored ECT (MMECT) where patients receive more than one treatment per anesthetic. Electroconvulsive therapy is not a required subject in US medical schools and not a required skill in psychiatric residency training. Privileging for ECT practice at institutions is a local option: no national certification standards are established, and no ECT-specific continuing training experiences are required of ECT practitioners.
In the United Kingdom in 1980, an estimated 50,000 people received ECT annually, with use declining steadily since then to about 12,000 per annum in 2002. It is still used in nearly all psychiatric hospitals, with a survey of ECT use from 2002 finding that 71 percent of patients were women and 46 percent were over 65 years of age. Eighty-one percent had a diagnosis of mood disorder; schizophrenia was the next most common diagnosis. Sixteen percent were treated without their consent. In 2003, the National Institute for Health and Care Excellence, a government body which was set up to standardize treatment throughout the National Health Service in England and Wales, issued guidance on the use of ECT. Its use was recommended "only to achieve rapid and short-term improvement of severe symptoms after an adequate trial of treatment options has proven ineffective and/or when the condition is considered to be potentially life-threatening in individuals with severe depressive illness, catatonia or a prolonged manic episode".
The guidance received a mixed reception. It was welcomed by an editorial in the British Medical Journal but the Royal College of Psychiatrists launched an unsuccessful appeal. The NICE guidance, as the British Medical Journal editorial points out, is only a policy statement and psychiatrists may deviate from it if they see fit. Adherence to standards has not been universal in the past. A survey of ECT use in 1980 found that more than half of ECT clinics failed to meet minimum standards set by the Royal College of Psychiatrists, with a later survey in 1998 finding that minimum standards were largely adhered to, but that two-thirds of clinics still fell short of current guidelines, particularly in the training and supervision of junior doctors involved in the procedure. A voluntary accreditation scheme, ECTAS, was set up in 2004 by the Royal College, but as of 2006 only a minority of ECT clinics in England, Wales, Northern Ireland and the Republic of Ireland have signed up.
ECT was introduced in China in the early 1950s and while it was originally practiced without anesthesia, as of 2012 almost all procedures were conducted with it. As of 2012, there are approximately 400 ECT machines in China, and 150,000 ECT treatments are performed each year. Chinese national practice guidelines recommend ECT for the treatment of schizophrenia, depressive disorders, and bipolar disorder and in the Chinese literature, ECT is an effective treatment for schizophrenia and mood disorders.
As early as the 16th century, agents to induce seizures were used to treat psychiatric conditions. In 1785, the therapeutic use of seizure induction was documented in the London Medical Journal. As to its earliest antecedents one doctor claims 1744 as the dawn of electricity's therapeutic use, as documented in the first issue of Electricity and Medicine. Treatment and cure of hysterical blindness was documented eleven years later. Benjamin Franklin wrote an electro static machine cured "a woman of hysterical fits." G.B.C. Duchenne, the mid-19th century "Father of Electrotherapy," said its use was integral to a neurological practice.
In the second half of the nineteenth century, such efforts were frequent enough in British asylums as to make it notable.
Convulsive therapy was introduced in 1934 by Hungarian neuropsychiatrist Ladislas J. Meduna who, believing mistakenly that schizophrenia and epilepsy were antagonistic disorders, induced seizures first with camphor and then metrazol (cardiazol). Ladislas Meduna is thought to be the father of convulsive therapy. In 1937, the first international meeting on convulsive therapy was held in Switzerland by the Swiss psychiatrist Muller. The proceedings were published in the American Journal of Psychiatry and, within three years, cardiazol convulsive therapy was being used worldwide. Italian Professor of neuropsychiatry Ugo Cerletti, who had been using electric shocks to produce seizures in animal experiments, and his colleague Lucio Bini developed the idea of using electricity as a substitute for metrazol in convulsive therapy and, in 1937, experimented for the first time on a person. It was known early on that inducing convulsions aided in helping those with severe schizophrenia. Cerletti had noted a shock to the head produced convulsions in dogs. The idea to use electroshock on humans came to Cerletti when he saw how pigs were given an electric shock before being butchered to put them in an anesthetized state. Cerletti and Bini practiced until they felt they had the right parameters needed to have a successful human trial. Once they started trials on patients they found that after 10-20 treatments the results were significant. Patients had much improved. A positive side effect to the treatment was retrograde amnesia. It was because of this side effect that patients could not remember the treatments and had no ill feelings toward it. ECT soon replaced metrazol therapy all over the world because it was cheaper, less frightening and more convenient. Cerletti and Bini were nominated for a Nobel Prize but did not receive one. By 1940, the procedure was introduced to both England and the US. In Germany and Austria it was promoted by Friedrich Meggendorfer. Through the 1940s and 1950s, the use of ECT became widespread.
In the early 1940s, in an attempt to reduce the memory disturbance and confusion associated with treatment, two modifications were introduced: the use of unilateral electrode placement and the replacement of sinusoidal current with brief pulse. It took many years for brief-pulse equipment to be widely adopted. In the 1940s and early 1950s ECT was usually given in "unmodified" form, without muscle relaxants, and the seizure resulted in a full-scale convulsion. A rare but serious complication of unmodified ECT was fracture or dislocation of the long bones. In the 1940s psychiatrists began to experiment with curare, the muscle-paralysing South American poison, in order to modify the convulsions. The introduction of suxamethonium (succinylcholine), a safer synthetic alternative to curare, in 1951 led to the more widespread use of "modified" ECT. A short-acting anesthetic was usually given in addition to the muscle relaxant in order to spare patients the terrifying feeling of suffocation that can be experienced with muscle relaxants.
The steady growth of antidepressant use along with negative depictions of ECT in the mass media led to a marked decline in the use of ECT during the 1950s to the 1970s. The Surgeon General stated there were problems with electroshock therapy in the initial years before anesthesia was routinely given, and that "these now-antiquated practices contributed to the negative portrayal of ECT in the popular media." The New York Times described the public's negative perception of ECT as being caused mainly by one movie. "For Big Nurse in One Flew Over the Cuckoo's Nest, it was a tool of terror, and, in the public mind, shock therapy has retained the tarnished image given it by Ken Kesey's novel: dangerous, inhumane and overused".
In 1976, Dr. Blatchley demonstrated the effectiveness of his constant current, brief pulse device ECT. This device eventually largely replaced earlier devices because of the reduction in cognitive side effects, although as of 2012 some ECT clinics still were using sine-wave devices. The 1970s saw the publication of the first American Psychiatric Association (APA) task force report on electroconvulsive therapy (to be followed by further reports in 1990 and 2001). The report endorsed the use of ECT in the treatment of depression. The decade also saw criticism of ECT. Specifically critics pointed to shortcomings such as noted side effects, the procedure being used as a form of abuse, and uneven application of ECT. The use of ECT declined until the 1980s, "when use began to increase amid growing awareness of its benefits and cost-effectiveness for treating severe depression". In 1985 the National Institute of Mental Health and National Institutes of Health convened a consensus development conference on ECT and concluded that, while ECT was the most controversial treatment in psychiatry and had significant side-effects, it had been shown to be effective for a narrow range of severe psychiatric disorders.
Because of the backlash noted previously, national institutions reviewed past practices and set new standards. In 1978, The American Psychiatric Association released its first task force report in which new standards for consent were introduced and the use of unilateral electrode placement was recommended. The 1985 NIMH Consensus Conference confirmed the therapeutic role of ECT in certain circumstances. The American Psychiatric Association released its second task force report in 1990 where specific details on the delivery, education, and training of ECT were documented. Finally in 2001 the American Psychiatric Association released its latest task force report. This report emphasizes the importance of informed consent, and the expanded role that the procedure has in modern medicine.
Society and culture
Surveys of public opinion, the testimony of former patients, legal restrictions on its use and disputes as to the efficacy, ethics and adverse effects of ECT within the psychiatric and wider medical community indicate that the use of ECT remains controversial. This is reflected in the recent vote by the United States Food and Drug Administration's (FDA's) Neurological Devices Advisory Panel to recommend that FDA maintain ECT devices in the Class III device category for high risk devices except for patients suffering from catatonia. This may result in the manufacturers of such devices having to do controlled trials on their safety and efficacy for the first time. In justifying their position, panelists referred to the memory loss associated with ECT and the lack of long-term data.
In the US, this doctrine places a legal obligation on a doctor to make a patient aware of: the reason for treatment, the risks and benefits of a proposed treatment, the risks and benefits of alternative treatment, and the risks and benefits of receiving no treatment. The patient is then given the opportunity to accept or reject the treatment. The form states how many treatments are recommended and also makes the patient aware that consent may be revoked and treatment discontinued at anytime during a course of ECT. The Surgeon General's Report on Mental Health states that patients should be warned that the benefits of ECT are short-lived without active continuation treatment in the form of drugs or further ECT, and that there may be some risk of permanent, severe memory loss after ECT. The report advises psychiatrists to involve patients in discussion, possibly with the aid of leaflets or videos, both before and during a course of ECT.
To demonstrate what he believes should be required to fully satisfy the legal obligation for informed consent, one psychiatrist, working for an anti-psychiatry organisation, has formulated his own consent form using the consent form developed and enacted by the Texas Legislature as a model.
According to the Surgeon General, involuntary treatment is uncommon in the United States and is typically used only in cases of great extremity, and only when all other treatment options have been exhausted. The use of ECT is believed to be a potentially life-saving treatment.
In one of the few jurisdictions where recent statistics on ECT usage are available, a national audit of ECT by the Scottish ECT Accreditation Network indicated that 77% of patients who received the treatment in 2008 were capable of giving informed consent.
In the UK, in order for consent to be valid it requires an explanation in "broad terms" of the nature of the procedure and its likely effects. One review from 2005 found that only about half of patients felt they were given sufficient information about ECT and its adverse effects and another survey found that about fifty percent of psychiatrists and nurses agreed with them.
A 2005 study published in the British Journal of Psychiatry described patients' perspectives on the adequacy of informed consent before ECT. The study found that, "About half (45–55%) of patients reported they were given an adequate explanation of ECT, implying a similar percentage felt they were not." The authors also stated:
"Approximately a third did not feel they had freely consented to ECT even when they had signed a consent form. The proportion who feel they did not freely choose the treatment has actually increased over time. The same themes arise whether the patient had received treatment a year ago or 30 years ago. Neither current nor proposed safeguards for patients are sufficient to ensure informed consent with respect to ECT, at least in England and Wales."
Procedures for involuntary ECT vary from country to country depending on local mental health laws.
In the United States, ECT devices came into existence prior to medical devices being regulated by the Food and Drug Administration; when the law came into effect the FDA was obligated to retrospectively review already existing devices and classify them, and determine whether clinical trials were needed to prove efficacy and safety. While the FDA has classified the devices used to administer ECT as Class III medical devices, as of 2011 the FDA had not yet determined whether the devices should be withdrawn from the market until clinical trials prove their safety and efficacy.:5 The FDA considers ECT machinery to be experimental devices. In most states in the USA, a judicial order following a formal hearing is needed before a patient can be forced to undergo involuntary ECT. However, ECT can also be involuntarily administered in situations with less immediate danger. Suicidal intent is a common justification for its involuntary use, especially when other treatments are ineffective.
Until 2009 in England and Wales, the Mental Health Act 1983 allowed the use of ECT on detained patients whether or not they had capacity to consent to it. However, following amendments which took effect in 2009, ECT may not generally be given to a patient who has capacity and refuses it, irrespective of his or her detention under the Act. In fact, even if a patient is deemed to lack capacity, if they made a valid advance decision refusing ECT then they should not be given it; and even if they do not have an advance decision, the psychiatrist must obtain an independent second opinion (which is also the case if the patient is under age of consent). However, there is an exception regardless of consent and capacity; under Section 62 of the Act, if the treating psychiatrist says the need for treatment is urgent they may start a course of ECT without authorization. From 2003 to 2005, about 2,000 people a year in England and Wales were treated without their consent under the Mental Health Act. Concerns have been raised by the official regulator that psychiatrists are too readily assuming that patients have the capacity to consent to their treatments, and that there is a worrying lack of independent advocacy. In Scotland the Mental Health (Care and Treatment) (Scotland) Act 2003 also gives patients with capacity the right to refuse ECT.
Public perception and mass media
A questionnaire survey of 379 members of the general public in Australia indicated that more than 60% of respondents had some knowledge about the main aspects of ECT. Participants were generally opposed to the use of ECT on depressed individuals with psychosocial issues, on children, and on involuntary patients. Public perceptions of ECT were found to be mainly negative.
Ernest Hemingway, American author, committed suicide shortly after ECT at the Mayo Clinic in 1961. He is reported to have said to his biographer, "Well, what is the sense of ruining my head and erasing my memory, which is my capital, and putting me out of business? It was a brilliant cure but we lost the patient...." American surgeon and award-winning author Sherwin B. Nuland is another notable person who has undergone ECT. In his 40s, this successful surgeon's depression became so severe that he had to be institutionalized. After exhausting all treatment options, a young resident assigned to his case suggested ECT, which ended up being successful.
Electroconvulsive therapy has been depicted in fiction, including fictional works partly based on true experiences. These include Sylvia Plath's autobiographical novel, The Bell Jar, and Ken Kesey's novel One Flew Over the Cuckoo's Nest; Kesey's novel is a direct product of his time working the graveyard shift as an orderly at a mental health facility in Menlo Park, California.
Throughout the history of ECT, women have received it two to three times as often as men, and continue to do so irrespective of diagnosis. A 1974 study of ECT in Massachusetts reported that women made up 69 per cent of those given ECT. The Ministry of Health in Canada reported that from 1999 until 2000 in Ontario, women were 71 per cent of those given ECT in provincial psychiatric institutions, and 75 per cent of the total ECT given was given to women. However, as of 1995 approximately 95 per cent of all doctors who administer ECT are men.
Some who oppose ECT do so because they consider it misogynist. For example, Dr. Bonnie Burstow (as of 2006, a faculty member in the Department of Adult Education and Couselling Psychology at the Ontario Institute for Studies in Education of the University of Toronto) has stated, "ECT constitutes state-sponsored violence against women. Indeed, it is state-sponsored violence against our most vulnerable sisters", in a 2006 paper entitled "Understanding and Ending ECT: A Feminist Imperative". 
- Rudorfer, MV, Henry, ME, Sackeim, HA (2003). "Electroconvulsive therapy". In A Tasman, J Kay, JA Lieberman (eds) Psychiatry, Second Edition. Chichester: John Wiley & Sons Ltd, 1865–1901.
- Beloucif S. Informed consent for special procedures: electroconvulsive therapy and psychosurgery. Curr Opin Anaesthesiol. 2013 PMID 23385317
- FDA. FDA Executive Summary. Prepared for the January 27–28, 2011 meeting of the Neurological Devices Panel Meeting to Discuss the Classification of Electroconvulsive Therapy Devices (ECT). Quote, p38: "Three major practice guidelines have been published on ECT. These guidelines include: APA Task Force on ECT (2001); Third report of the Royal College of Psychiatrists’ Special Committee on ECT (2004); National Institute for Health and Clinical Excellence (NICE 2003; NICE 2009). There is significant agreement between the three sets of recommendations."
- Dierckx, B.; Heijnen, WT; Van Den Broek, WW; Birkenhäger, TK (2012). "Efficacy of electroconvulsive therapy in bipolar versus unipolar major depression: A meta-analysis". Bipolar Disorders 12 (2): 146–150. doi:10.1111/j.1399-5618.2012.00997.x. PMID 22420590.
- Jelovac A et al. Relapse following successful electroconvulsive therapy for major depression: a meta-analysis. Neuropsychopharmacology. 2013 Nov;38(12):2467-74. PMID 23774532 PMC 3799066
- Surgeon General (1999). Mental Health: A Report of the Surgeon General, chapter 4.
- American Psychiatric Association; Committee on Electroconvulsive Therapy; Richard D. Weiner (chairperson) et al. (2001). The practice of electroconvulsive therapy: recommendations for treatment, training, and privileging (2nd ed.). Washington, DC: American Psychiatric Publishing. ISBN 978-0-89042-206-9.
- Pompili M, et al. Electroconvulsive treatment during pregnancy: a systematic review. Expert Rev Neurother. 2014 Dec;14(12):1377-90. PMID 25346216
- Margarita Tartakovsky (2012) Psych Central. 5 Outdated Beliefs About ECT
- Dr.Barnes, Richard. "Information on ECT". Royal College of Psychiatrists' Special Committee on ECT and related treatment. Retrieved 3 November 2013.
- Read, J; Bentall, R (Oct–Dec 2010). "The effectiveness of electroconvulsive therapy: a literature review." (PDF). Epidemiologia e psichiatria sociale 19 (4): 333–47. doi:10.1017/S1121189X00000671. PMID 21322506.
- Abbott CC, et al A review of longitudinal electroconvulsive therapy: neuroimaging investigations. J Geriatr Psychiatry Neurol. 2014 Mar;27(1):33-46. Review. PMID 24381234
- World Health Organisation (2005). WHO Resource Book on Mental Health, Human Rights and Legislation. Geneva, 64.
- Fitzgerald PB. Non-pharmacological biological treatment approaches to difficult-to-treat depression Med J Aust. 2013 Sep 16;199(6 Suppl):S48-51. Review. PMID 25370288
- "Depression in adults: The treatment and management of depression in adults. NICE guidelines CG90". National Institute for Clinical Excellence. 2009.
- Lipsman N, et al. Neuromodulation for treatment-refractory major depressive disorder. CMAJ. 2014 Jan 7;186(1):33-9. PMID 23897945
- Murray ED, Buttner N, Price BH (2012). "Depression and Psychosis in Neurological Practice". In Bradley WG, Daroff RB, Fenichel GM, Jankovic J. Bradley's Neurology in Clinical Practice: Expert Consult - Online and Print, 6e (Bradley, Neurology in Clinical Practice e-dition 2v Set) 1 (6th ed.). Philadelphia, PA: Elsevier/Saunders. pp. 114–115. ISBN 1-4377-0434-4.
- Daniel Pagnin, M.D., M.Sc.; Valéria de Queiroz, M.D., M.Sc.; Stefano Pini, M.D.; Giovanni Battista Cassano, M.D. "Efficacy of ECT in Depression: A Meta-Analytic Review". Focus.
- UK ECT Review Group (2003). "Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis". The Lancet 361 (9360): 799–808. doi:10.1016/S0140-6736(03)12705-5. PMID 12642045.
- Micallef-Trigona B. Comparing the effects of repetitive transcranial magnetic stimulation and electroconvulsive therapy in the treatment of depression: a systematic review and meta-analysis. Depress Res Treat. 2014;2014:135049. Review. PMID 25143831 PMC 4131106
- Sienaert P, et al. A clinical review of the treatment of catatonia. Front Psychiatry. 2014 Dec 9;5:181. Review. PMID 25538636 PMC4 260674
- DeJong H, et al. A systematic review of interventions used to treat catatonic symptoms in people with autistic spectrum disorders. J Autism Dev Disord. 2014 Sep;44(9):2127-36. Review.PMID 24643578
- NICE Guidance on the use of electroconvulsive therapy. NICE technology appraisals TA59. Published date: April 2003
- Kanba S, Kato T, Terao T, Yamada K; Committee for Treatment Guidelines of Mood Disorders, Japanese Society of Mood Disorders, 2012. Guideline for treatment of bipolar disorder by the Japanese Society of Mood Disorders, 2012. Psychiatry Clin Neurosci. 2013 Jul;67(5):285-300. Review. PMID 23773266
- Malhi GS, et al. Mania: diagnosis and treatment recommendations. Curr Psychiatry Rep. 2012 Dec;14(6):676-86. Review. PMID 22986995
- Tharyan, P. Adams, C.E. (2005). Tharyan, Prathap, ed. "Electroconvulsive therapy for schizophrenia". The Cochrane Database of Systematic Reviews (2): CD000076. doi:10.1002/14651858.CD000076.pub2. PMID 15846598.
- Haskett RF and Loo C (2010) Role of Adjunctive Psychotropic Medications during ECT in the Treatment of Depression, Mania and Schizophrenia J ECT. 2010 September; 26(3): 196–20
- Prudic J, Olfson M, Sackeim HA (July 2001). "Electro-convulsive therapy practices in the community". Psychol Med 31 (5): 929–34. doi:10.1017/S0033291701003750. PMID 11459391.
- Royal College of Psychiatrists. Council Report. The ECT Handbook: The Third Report of the Royal College of Psychiatrists' Special Committee of ECT. RCPsych Publications, 2005 ISBN 9781904671220
- Duffett R, Lelliott P (1998). "Auditing electroconvulsive therapy. The third cycle". Br J Psychiatry 172 (5): 401–5. doi:10.1192/bjp.172.5.401. PMID 9747401.
- Lock, T (1995). "Stimulus dosing". In C Freeman (ed.) The ECT Handbook. London: Royal College of Psychiatrists, 72–87.
- Motohashi N, Awata S, Higuchi T (2004). "A questionnaire survey of ECT practice in university hospitals and national hospitals in Japan". J ECT 20 (1): 21–3. doi:10.1097/00124509-200403000-00005. PMID 15087992.
- Chanpattana W, Kunigiri G, Kramer BA, Gangadhar BN (2005). "Survey of the practice of electroconvulsive therapy in teaching hospitals in India". J ECT 21 (2): 100–4. doi:10.1097/01.yct.0000166634.73555.e6. PMID 15905751.
- Ikeji OC, Ohaeri JU, Osahon RO, Agidee RO (1999). "Naturalistic comparative study of outcome and cognitive effects of unmodified electro-convulsive therapy in schizophrenia, mania and severe depression in Nigeria". East Afr Med J 76 (11): 644–50. PMID 10734527.
- Teena Thacker for Indian Express. Mar 23 2011 Electroshocks for mentally ill patients to be banned
- Kala A. Time to face new realities; mental health care bill-2013. Indian J Psychiatry. 2013 Jul;55(3):216-9. doi:10.4103/0019-5545.117129 PMID 24082240
- Dutta, Rita (2003). "Psychiatrists plead against ban of direct electro convulsive therapy". Indian Express Group of Newspapers. Retrieved 2007-12-31.
- "Abusive practice of "unmodified" electroshock treatment abolished at main psychiatric facility of Turkey". Disabled Peoples' International. Retrieved 2008-03-25.
- Corinne Slusher for MedScape. Updated: Jan 6, 2012 Electroconvulsive Therapy Machine
- Ectron: Our story
- "Electroconvulsive therapy – Electroshock (ECT)". DoctorsLounge. Retrieved 2009-03-19.
- O'Neill, J; Haupt, Robert (2 August 1988). "The last victim of the 'beautiful hospital'". Sydney Morning Herald.
- E. Wilson 2003 Psychiatric abuse at Chelmsford Private Hospital, New South Wales, 1960-1980s. In C. Coleborne and D. MacKinnon Madness in Australia: histories, heritage and the asylum. Queensland: 121-34
- Susan Jane Tweedale v. Dr. John Tennant Herron & Ors.,  NSWSC 168 AustLII (Supreme Court of New South Wales 10 December 1996).
- Gelder, M., Mayou, R., Geddes, J. (2006) Psychiatry. 3rd edition. Oxford: Oxford University Press
- Gallegos J; Vaidya P; D'Agati D et al. (June 2012). "Decreasing adverse outcomes of unmodified electroconvulsive therapy: suggestions and possibilities". J ECT 28 (2): 77–81. doi:10.1097/YCT.0b013e3182359314. PMID 22531198.
- Lisanby SH, Maddox JH, Prudic J, Devanand DP, Sackeim HA (June 2000). "The effects of electroconvulsive therapy on memory of autobiographical and public events". Arch. Gen. Psychiatry 57 (6): 581–90. doi:10.1001/archpsyc.57.6.581. PMID 10839336.
- Semkovska M, McLoughlin DM. Measuring retrograde autobiographical amnesia following electroconvulsive therapy: historical perspective and current issues. J ECT. 2013 Jun;29(2):127-33. Review. PMID 23303426
- Benbow, SM (2004) "Adverse effects of ECT". In AIF Scott (ed.) The ECT Handbook, second edition. London: The Royal College of Psychiatrists, pp. 170–174.
- Squire LR, Slater PC, Miller PL (January 1981). "Retrograde amnesia and bilateral electroconvulsive therapy. Long-term follow-up". Arch. Gen. Psychiatry 38 (1): 89–95. doi:10.1001/archpsyc.1981.01780260091010. PMID 7458573.
- Squire LR, Slater PC (January 1983). "Electroconvulsive therapy and complaints of memory dysfunction: a prospective three-year follow-up study". Br J Psychiatry 142: 1–8. doi:10.1192/bjp.142.1.1. PMID 6831121.
- Rose, D; Fleischmann, P; Wykes, T; Leese, M; Bindman, J (2003). "Patients' perspectives on electroconvulsive therapy: systematic review". British Medical Journal 326 (7403): 1363–1365. doi:10.1136/bmj.326.7403.1363. PMC 162130. PMID 12816822.
- Mental Health: A Report of the Surgeon General – Chapter 4. Retrieved 2007-12-29.
- Sussman, M.D., Norman (December 2006). "In Session with Charles H. Kellner, MD: Current Developments in Electroconvulsive Therapy". Primary Psychiatry 2007;14(3):34-37. Retrieved 2009-10-17.
- Devanand DP; Sackeim HA et al. (July 1991). "Absence of cognitive impairment after more than 100 lifetime ECT treatments". The American Journal of Psychiatry 148 (7): 929–32. PMID 2053635.
- Richards EM, Payne JL. The management of mood disorders in pregnancy: alternatives to antidepressants CNS Spectr. 2013 Oct;18(5):261-71. Review. PMID 23570692
- Leiknes KA, et al (2012) Contemporary use and practice of electroconvulsive therapy worldwide. Brain Behav. 2(3):283-344
- See the Slovenian government website for information about ECT in Slovenia.
- Reid WH, Keller S, Leatherman M, Mason M (January 1998). "ECT in Texas: 19 months of mandatory reporting". J Clin Psychiatry 59 (1): 8–13. doi:10.4088/JCP.v59n0103. PMID 9491059.
- Euba R, Saiz A (2006). "A comparison of the ethnic distribution in the depressed inpatient population and in the electroconvulsive therapy clinic". J ECT 22 (4): 235–6. doi:10.1097/01.yct.0000235928.39279.52. PMID 17143151.
- Rise In Electric Shock Therapy In County. Sarah Hall, Norwich Evening News 24, June 4, 2008. Accessed: June 4, 2008.
- Hermann R, Dorwart R, Hoover C, Brody J (1995). "Variation in ECT use in the United States". Am J Psychiatry 152 (6): 869–75. doi:10.1176/ajp.152.6.869. PMID 7755116.
- Cauchon, Dennis (1995-12-06). "Patients often aren't informed of full danger". USA Today.
- "Electroconvulsive Therapy in Children" by Edward Shorter, Ph.D. December 1, 2013
- Texas Department of State (2002) Electroconvulsive therapy reports.
- Fink, M. & Taylor, A.M. (2007) Electroconvulsive therapy: Evidence and Challenges JAMA Vol. 298 No. 3, p330–332.
- Pippard J, Ellam L (1981). "Electroconvulsion treatment in Great Britain 1980". Lancet 2 (8256): 1160–1. PMID 6118592.
- Electro convulsive therapy: survey covering the period from January 2002 to March 2002. . Department of Health.
- NICE 2003. Electroconvulsive therapy (ECT). Retrieved on 2007-12-29.
- Carney, S; Geddes, J (2003). "Electroconvulsive therapy: recent recommendations are likely to improve standards and uniformity of use". British Medical Journal 326 (7403): 1343–4. doi:10.1136/bmj.326.7403.1343. PMC 1126234. PMID 12816798.
- NICE (2003). Appraisal of electroconvulsive therapy: decision of the appeal panel. London: NICE.
- Duffett, R; Lelliott, P (1998). "Auditing electroconvulsive therapy: the third cycle". British Journal of Psychiatry 172 (5): 401–405. doi:10.1192/bjp.172.5.401. PMID 9747401.
- Royal College of Psychiatrists (2006). ECTAS newsletter issue 5.
- Tang YL, et al. Electroconvulsive therapy in China: clinical practice and research on efficacy. J ECT. 2012 Dec;28(4):206-12. PMID 22801297
- A History of Mental Institutions in the United States which says electrostatic machines were used in 1773
- Electroconsulsive Therapy – A History using date of 1746
- Wright, Bruce A. M.D. "An Historical Review of Electro Convulsive Therapy". Jefferson Journal of Psychiatry: 66–74.
- Beveridge, A. W.; Renvoize, E. B. (1988). "Electricity: A History of its use in the Treatment of Mental Illness in Britain During the Second Half of the 19th Century" (PDF). British Journal of Psychiatry: 153, 157–162. Retrieved 28 December 2014.
- Berrios, G E (1997). "The scientific origins of electroconvulsive therapy". History of Psychiatry 8 (29 pt 1): 105–119. doi:10.1177/0957154X9700802908. PMID 11619203.
- Fink, M (1984). "The origins of convulsive therapy". American Journal of Psychiatry 141 (9): 1034–41. PMID 6147103.
- Bolwig, T. (2011). "How does electroconvulsive therapy work? Theories on its mechanism". The Canadian Journal of Psychiatry 51 (1): 13–18. PMID 21324238.
- Sabbatini, R. "The history of shock therapy in psychiatry". Retrieved 2013-04-24.
- Cerletti, U (1956). "Electroshock therapy". In AM Sackler et al. (eds) The Great Physiodynamic Therapies in Psychiatry: an historical appraisal. New York: Hoeber-Harper, 91–120.
- Kiloh, LG, Smith, JS, Johnson, GF (1988). Physical Treatments in Psychiatry. Melbourne: Blackwell Scientific Publications, 190–208. ISBN 0-86793-112-4
- Goode, Erica (1999-10-06). "Federal Report Praising Electroshock Stirs Uproar". New York Times. Retrieved 2008-01-01.
- Goleman, Daniel (1990-08-02). "The Quiet Comeback of Electroshock Therapy". The New York Times. p. B5. Retrieved 2008-01-01.
- See Friedberg, J (1977). "Shock treatment, brain damage, and memory loss: a neurological perspective". American Journal of Psychiatry 134:1010–1014; and Breggin, PR (1979) Electroshock: its brain-disabling effects. New York: Springer
- Blaine, JD; Clark, SM (1986). "Report of the NIMH–NIH consensus development conference on Electroconvulsive therapy". Psychopharmacology Bulletin 22 (2): 445–452.
- Fisher P. Psychological factors related to the experience of and reaction to electroconvulsive therapy. J Ment Health. 2012 Dec;21(6):589-99. Review. PMID 23216225
- Philpot, M; Treloar, A; Gormley, N; Gustafson, L (2002). "Barriers to the use of electroconvulsive therapy in the elderly: a European survey". European Psychiatry 17 (1): 41–45. doi:10.1016/S0924-9338(02)00620-X. PMID 11918992.
- Whitaker, Robert (2010). Mad in America : bad science, bad medicine, and the enduring mistreatment of the mentally ill (Rev. pbk. ed.). New York, NY: Basic Books. pp. 102–106. ISBN 978-0-465-02014-0.
- Golenkov, A.; Ungvari, G. S.; Gazdag, G. (21 February 2011). "Public attitudes towards electroconvulsive therapy in the Chuvash Republic". International Journal of Social Psychiatry 58 (3): 289–94. doi:10.1177/0020764010394282. PMID 21339235.
- Committee on Mental Health (March 2002). "Report on Electroconvulsive Therapy". New York State Assembly. Retrieved 8 March 2011.
- Melding, P (2006-07-07). "Electroconvulsive therapy in New Zealand: terrifying or electrifying?". The New Zealand medical journal 119 (1237): U2051. PMID 16862197.
- Teh, S.P.C.; Helmes, E.; Drake, D. (2007). "A Western Australian Survey On Public Attitudes Toward and Knowledge of Electroconvulsive Therapy". International Journal of Social Psychiatry 53 (3): 247–271. doi:10.1177/0020764006074522.
- Kellner, Charles H. (2012-07-05). "The FDA Advisory Panel on the Reclassification of ECT Devices: Unjustified Ambivalence". Psychiatric Times. UBM Medica. Archived from the original on 2012-10-25. Retrieved 2012-10-25.
- Duff Wilson for the New York Times. January 28, 2011 F.D.A. Panel Is Split on Electroshock Risks
- Mechcatie, Elizabeth. "FDA Regulation of ECT Devices in Transition". Clinical Psychiatry News. Retrieved 8 March 2011.
- Johnson, R. "An informed consent form for electroconvulsive therapy, draft 1." (PDF). PsychRights.
- Texas Legislature (2004). Health & Safety Code Chapter 578, Electroconvulsive And Other Therapies Sec.578.001.
- Fergusson G (ed) "et al." (2009). "The Scottish ECT Accreditation Network (SEÁN) Annual Report 2009" (PDF). Scottish ECT Accreditation Network. Retrieved 2010-05-24.
- Jones, R (1996) Mental Health Act Manual, 5th edition. London: Sweet and Maxwell, page 225.
- Rose D, Wykes T, Bindman J, Fleischmann P (2005)"Information, consent and perceived coercion: patients' perspectives on electroconvulsive therapy". British Journal of Psychiatry 186:54–59.
- Lutchman, RD et al. (2001). "Mental health professionals' attitudes towards and knowledge of electroconvulsive therapy". Journal of Mental Health 10 (20): 141–150. doi:10.1080/09638230124779.
- Committee on Mental Health (March 2002). "Report on Electroconvulsive Therapy:EXECUTIVE SUMMARY". New York State Assembly. Retrieved 8 March 2011.
- The Mental Health Act 1983 (updated version) Part IV, Section 58. Care Quality Commission[dead link]
- Care Quality Commission (2010) ECT: Your rights about consent to treatment
- The Mental Health Act 1983 (updated version) Part IV, Section 62. Care Quality Commission
- The Mental Health Act Commission (2005) In Place of Fear? eleventh biennial report, 2003–2005, 236. The Stationery Office.
- "CQC says care for people treated under the Mental Health Act still needs to improve". Care Quality Commission. 8 December 2011. Archived from the original on 21 May 2015.
- The Mental Health (Care and Treatment) (Scotland) Act 2003, Part 16, sections 237–239.
- A. E. Hotchner, Papa Hemingway: A Personal Memoir, ISBN 0-7867-0592-2; pg 280
- "Sherwin Nuland: How electroshock therapy changed me | Talk Subtitles and Transcript". TED.com. Retrieved 2015-05-19.
- C.H. Kellner, Electroconvulsive Therapy (ECT) in Literature: Sylvia Plath's The Bell Jar, Prog Brain Res. 2013;206:219-28. PMID 24290484
- Mitchell Snyder, p. 174
- "Report of the Electro-convulsive Therapy Review Committee." Toronto: Electro-convulsive Therapy Review Committee, 1985.
- Grosser, G. “The Regulation of Electroshock Treatment in Massachusetts.” Massachusetts Journal of Mental Health 5 (1975):12-25.
- Weitz, D. “Ontario Electroshock Statistics.” Figures released under the Freedom of Information Act. Toronto: Ontario. Ministry of Health, 2001.
- Grobe, J. Beyond Bedlam. Chicago: Third Side Press, 1995.
- "Understanding and Ending ECT: A Feminist Imperative | Bonnie J Burstow". Academia.edu. 1970-01-01. Retrieved 2015-05-19.
|Wikimedia Commons has media related to Electroconvulsive therapy.|
- Position Statement on Electroconvulsive Therapy (ECT) [PDF] – from the American Psychiatric Association.
- MIND on ECT – information on ECT from MIND (leading mental health charity in England and Wales).
- ECT - information from mental health charity The Royal College of Psychiatrists