ECT earned its stigma historically, but today it is a quick procedure under general anesthesia and one of the most effective, safe treatments we have, with the best evidence in treatment-resistant depression. Raise it when you start the second medication trial, and think of it early for psychotic depression (especially in older patients), catatonia and dangerous illness in pregnancy. Consent should cover memory head-on, the practical burden of the schedule, and the fact that doing nothing has costs too.
What it is
ECT got its stigma for good reasons. It is also incredibly effective and incredibly safe, and in the right population it can relieve a great deal of suffering.
“ECT has a lot of stigma. It got stigma for good reasons. It's also incredibly effective. It's incredibly safe. And it can be a very important tool that can alleviate suffering in the right population”
9:26ECT Treatment: When to Refer, Who It Helps, and What Actually Happens with Dr. MaryEllen EllerJun 2026Guest episode It is given under general anesthesia with a paralytic. The patient is fully asleep and relaxed, no movement is seen, and the seizure is confirmed on EEG.
“the way that it's delivered, it's delivered using general anesthesia. So the human is fully asleep. Their body is fully relaxed with a paralytic. There's no movement observed. The only way to know that a seizure has occurred is by monitoring with an EEG”
16:35ECT Treatment: When to Refer, Who It Helps, and What Actually Happens with Dr. MaryEllen EllerJun 2026Guest episode Targeted neuromodulation tries to stimulate one circuit directly and bypass the receptors. ECT does the opposite: it picks no single circuit and affects all of them by inducing a seizure.
“Maybe I can bypass the receptor set and I can just directly stimulate that circuit using cool principles with like electromagnets and inducing currents”
33:35ECT Treatment: When to Refer, Who It Helps, and What Actually Happens with Dr. MaryEllen EllerJun 2026Guest episode Also said in 1 more episode
“ECT says, I am not going to pick one circuit. I am going to affect all the circuits. And that is the process of inducing a seizure”
34:55ECT Treatment: When to Refer, Who It Helps, and What Actually Happens with Dr. MaryEllen EllerJun 2026Guest episode It arose in an era when someone admitted to an asylum with depression, schizophrenia or bipolar disorder would usually never leave.
“In the early 1930s, right, if you were diagnosed with something like depression and schizophrenia, bipolar disorder, the reality for most people is you'd be admitted to an insane asylum and you would never leave”
12:16ECT Treatment: When to Refer, Who It Helps, and What Actually Happens with Dr. MaryEllen EllerJun 2026Guest episode
When we reach for it
Start the conversation about ECT and other neuromodulation the moment you start medication trial number two.
“Usually this conversation, we should start having it the moment we start medication trial number two, right”
36:54ECT Treatment: When to Refer, Who It Helps, and What Actually Happens with Dr. MaryEllen EllerJun 2026Guest episode For treatment-resistant depression, the best evidence goes to ECT and TMS, then antipsychotics (aripiprazole with the best evidence and biggest effect size), lithium, thyroid supplement, and ketamine or esketamine.
“The best evidence goes to ECT, TMS, TMS. antipsychotics, particularly aripiprazole has the best evidence and the biggest effect size, lithium, thyroid supplement, and the ketamines, esketamine and ketamine. So those would be our top line interventions”
6:46The Deficit Model in Psychiatry & Difficult to Treat Depression with Dr. Chris Aiken | Episode 18Mar 2025Guest episode Depression with psychosis responds incredibly well to ECT and poorly to other things, and the older the patient, the better the response. In an outpatient clinic, psychotic depression in an older person should make you think of ECT right away.
“things that respond incredibly well to ECT and poorly to other things. Depression with psychosis. Interestingly, the older you are, the better your response rates”
43:07ECT Treatment: When to Refer, Who It Helps, and What Actually Happens with Dr. MaryEllen EllerJun 2026Guest episode Also said in 1 more episode
“in an ambulatory outpatient setting, the moment you see depression with psychotic features, especially in older individuals, That's a human that would be a really, really good ECT candidate”
43:52ECT Treatment: When to Refer, Who It Helps, and What Actually Happens with Dr. MaryEllen EllerJun 2026Guest episode In pregnancy, when mania, psychosis or depression puts the mother and fetus at risk, ECT is effective and rapidly acting.
“pregnancy, especially if a pregnant female is experiencing mania or psychosis or depression that is putting her life and the life of her fetus at risk, ECT is effective and it is rapidly acting”
45:14ECT Treatment: When to Refer, Who It Helps, and What Actually Happens with Dr. MaryEllen EllerJun 2026Guest episode TMS is better tolerated, less feared and far more available. ECT remains the choice for very serious cases.
“Great choice along with ECT for very serious cases. But TMS, of course, better tolerated. Most people aren't as afraid of it. Probably more available by far than ECT these days, I would think. Yeah, I've had patients who had nice response from TMS”
55:14Treating Depression: Practical Tips & Pearls for Anti-Depressant MedicationsJan 2025
Dosing and course
Major depression: expect about 12 treatments, three a week.
“When I'm consenting somebody for ECT for major depressive disorder, I expect them to do 12 treatments. We try to do three treatments a week”
49:24ECT Treatment: When to Refer, Who It Helps, and What Actually Happens with Dr. MaryEllen EllerJun 2026Guest episode Catatonia: three treatments a week until the patient is no longer catatonic, which might be one treatment or 12.
“in a disease like catatonia, the answer is you're going to do ECT treatments three times a week until you're not catatonic. That might be one treatment. That might be 12”
49:00ECT Treatment: When to Refer, Who It Helps, and What Actually Happens with Dr. MaryEllen EllerJun 2026Guest episode Bipolar disorder: whichever phase you are treating, treat to symptom remission plus three.
“we treat whatever side of the disease phase that we're in, we treat to symptom remission plus three”
50:23ECT Treatment: When to Refer, Who It Helps, and What Actually Happens with Dr. MaryEllen EllerJun 2026Guest episode The goal after the index course is to stay in remission, so maintenance usually starts one month after it ends.
“Once we get done with ECT, the goal is to stay in remission. So typically what we'll do, I'll have somebody come back for maintenance treatment one month after they finish their index course”
51:50ECT Treatment: When to Refer, Who It Helps, and What Actually Happens with Dr. MaryEllen EllerJun 2026Guest episode
Side effects and safety
Common side effects come from the anesthesia and paralytic: headache, nausea, muscle stiffness or soreness, and confusion on waking that usually lasts 15 minutes or less.
“So headache, nausea, muscle stiffness or soreness from the paralytic agent, nausea as you're waking up. And you should be confused after you're coming out of general anesthesia, but that confusion usually lasts 15 minutes or less”
46:12ECT Treatment: When to Refer, Who It Helps, and What Actually Happens with Dr. MaryEllen EllerJun 2026Guest episode Memory: 30 to 40 percent of people in their index series have a better mini mental status exam score by the sixth treatment, despite the seizures and anesthesia.
“over 30%, so between 30% and 40% of individuals who are in the midst of their index series have a better mini mental status exam score despite seizures and anesthesia exposure by their sixth treatment”
47:51ECT Treatment: When to Refer, Who It Helps, and What Actually Happens with Dr. MaryEllen EllerJun 2026Guest episode There is no absolute contraindication, but every seizure brings a parasympathetic surge, with blood pressure and heart rate dropping during the seizure itself, so cardiovascular history matters.
“there's no absolute contraindication for ECT. However, anytime you have a seizure, you get a parasympathetic surge during the seizure itself. So your blood pressure goes low and your heart rate goes low”
44:10ECT Treatment: When to Refer, Who It Helps, and What Actually Happens with Dr. MaryEllen EllerJun 2026Guest episode No driving for 24 hours after anesthesia, so ECT is not the right choice for someone trying to keep working during the course.
“Anytime you're under general anesthesia, you may not operate a motor vehicle for 24 hours post-anesthesia. So ECT is not the right choice for people who are trying to actively work while getting treatment”
52:44ECT Treatment: When to Refer, Who It Helps, and What Actually Happens with Dr. MaryEllen EllerJun 2026Guest episode
Talking to patients and families
Memory is the biggest fear, so have an explicit conversation about the memory risks as part of informed consent.
“The biggest resistance for most people is the fear around memory and memory concerns. Having explicit conversations around what those risks are is really important as far as an informed consent is concerned”
42:15ECT Treatment: When to Refer, Who It Helps, and What Actually Happens with Dr. MaryEllen EllerJun 2026Guest episode Resistance often comes from the spouse or parents, who have heard it will wipe out memory or change their loved one. Address them directly.
“often it's their support, the support around them, husband, wife, parents, that has the most resistance to the idea of doing ECT because they've heard that it's going to wipe out their memory, it's going to turn my loved one into somebody completely different”
40:30ECT Treatment: When to Refer, Who It Helps, and What Actually Happens with Dr. MaryEllen EllerJun 2026Guest episode Doing nothing is a treatment option, and letting the illness run its course has profound effects of its own. Say so in consent.
“it's critical for people to know that doing nothing is a treatment option. They can choose not to treat their disease, but doing nothing and allowing a disease process to run rampant or run its course can have profound impacts”
48:16ECT Treatment: When to Refer, Who It Helps, and What Actually Happens with Dr. MaryEllen EllerJun 2026Guest episode By the time patients reach ECT, they have often had more than 12 medication trials and feel this is the last stop. Expect hopelessness.
“Oftentimes when somebody is getting referred to me for ECT, the average number of medication trials is greater than 12. By the time they show up, they're feeling hopeless. They're feeling like this is the last stop on their journey”
38:05ECT Treatment: When to Refer, Who It Helps, and What Actually Happens with Dr. MaryEllen EllerJun 2026Guest episode Actively suicidal patients may hear there is a chance of dying under anesthesia and take that as a reason to sign up. Consent then needs a careful conversation.
“I have had to have some creative conversations around informed consent for individuals who had depression and were actively suicidal and they hear that under general anesthesia there's a chance of dying and that's their indication that they want to sign up”
40:01ECT Treatment: When to Refer, Who It Helps, and What Actually Happens with Dr. MaryEllen EllerJun 2026Guest episode
Pitfalls and myths
Most of psychiatry is medication, next medication, next medication, and ECT is not even in the algorithm for many prescribers.
“right now, psychiatry, like 95% is practice of medication, next medication, next medication, next medication. And that's not in the algorithm”
25:21ECT Treatment: When to Refer, Who It Helps, and What Actually Happens with Dr. MaryEllen EllerJun 2026
From these episodes
- ECT Treatment: When to Refer, Who It Helps, and What Actually Happens with Dr. MaryEllen EllerJun 2026 · 23 points
- The Deficit Model in Psychiatry & Difficult to Treat Depression with Dr. Chris Aiken | Episode 18Mar 2025 · 1 point
- Treating Depression: Practical Tips & Pearls for Anti-Depressant MedicationsJan 2025 · 1 point
Every point above is something said on the Psychofarm podcast, with the words as spoken and a link to the moment in the episode. It is education, not medical advice, and an episode reflects what we thought when we recorded it.