Major depressive disorder ECT

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mitra Chitsazan, M.D.[2] Aiden Nguyen[3]

Overview

Electroconvulsive therapy (ECT) is the most effective acute treatment for severe major depressive disorder (MDD). Most guidelines position ECT as first-line for severe, life-threatening episodes (psychotic features, catatonia, high suicide risk, or food/fluid refusal) and as second-line for severe MDD unresponsive to pharmacotherapy or psychotherapy. NICE's earlier (2003/2009) guidance was more restrictive. ECT is recommended (US Department of Veterans Affairs/Department of Defense [VA/DoD] 2022, Strong for, despite very low-quality evidence, because of the life-threatening nature of these presentations) among patients with severe MDD who have catatonia, psychotic depression, severe suicidality, a history of good response to ECT, or a need for a rapid, definitive response, and among patients with poor response or intolerance to multiple antidepressants. MDD with malignant catatonia requires urgent ECT. Modified ECT (general anesthesia plus neuromuscular blockade) is the standard technique. Right unilateral (RUL) ECT at about 6 times seizure threshold is commonly used first in nonpsychotic patients. Ultrabrief-pulse RUL causes fewer cognitive effects but is less effective and requires more sessions than brief-pulse RUL. Bitemporal placement is favored for psychotic, catatonic, or urgent presentations. Relapse after a successful ECT course is common, and expert consensus supports lithium plus an antidepressant, with tapered continuation/maintenance ECT in high-risk patients.

Electroconvulsive Therapy

Regulatory Status

  • In 2018 the US FDA reclassified ECT devices from class III (high risk) to class II (moderate risk, special controls).[1]
  • The class II indication is severe major unipolar or bipolar depressive episodes, or catatonia, in patients aged 13 years or older whose illness is treatment-resistant or who need a rapid response because of the severity of their psychiatric or medical condition.[2]
  • The FDA did not define "severe" or "treatment-resistant." Other uses are left to clinical judgment.[2]

Indications

1. US Department of Veterans Affairs/Department of Defense (VA/DoD) 2022 (Strong for, very low-quality evidence)

Offer ECT, with or without psychotherapy, to patients with severe MDD and any of the following:[3]

  • Catatonia
  • Psychotic depression
  • Severe suicidality
  • History of good response to ECT
  • Need for a rapid, definitive response on medical or psychiatric grounds
  • Risks of other treatments exceed the risks of ECT (for example, comorbidities that make ECT the safest option)
  • Poor response or intolerable side effects to multiple antidepressants
Other International Guidelines

Older guidelines (APA 2010, CANMAT 2016, RANZCP 2015, WFSBP 2013, NICE 2009), as summarized in the background of Cochrane review protocols:[4]

  • First-line for depression with psychosis, catatonia, refusal to eat or drink, or high suicide risk.
  • First-line for treatment-resistant acute episodes (CANMAT, NICE, WFSBP).
  • Pregnancy: first-line when medication is contraindicated (WFSBP). APA and RANZCP suggest ECT as a treatment of choice for severe depression in pregnancy.
  • Continuation/maintenance ECT: considered after acute response by APA, CANMAT, and RANZCP; NICE 2009 judged the evidence insufficient to make a recommendation.[5]

These positions predate the CANMAT 2023 and NICE 2022 (NG222) updates:

  • CANMAT 2023: for depression that does not improve with adjunctive pharmacotherapy, psychiatric referral for evaluation and possible neuromodulation, such as ECT or repetitive transcranial magnetic stimulation, should be considered.[6][7]
  • NICE 2022 (NG222): described in the VA/DoD guideline synopsis as recommending ECT in contexts similar to VA/DoD.[8] NICE's earlier guidance restricted ECT to severe, life-threatening illness or failure of an adequate trial of other treatments, in contrast with APA, WFSBP, RCPsych, RANZCP, and CANMAT, which do not regard ECT as a last resort.[9]

2. Catatonia

  • Start ECT as soon as possible after limited response to benzodiazepines, or for severe catatonia. Start urgently for any malignant catatonia.[10]
  • In malignant catatonia, if benzodiazepines are not rapidly effective, ECT should be started within 48–72 hours of onset. Bilateral treatments daily or twice daily for up to 3–5 days are often needed, followed by ECT 3 times weekly until sustained improvement (usually 5–20 treatments in total). In a historical (1952) case series, 16 of 19 patients who began ECT within 5 days of onset survived, compared with none of 14 who began later.[11]
  • ECT improves 80–100% of catatonia, including up to 60% of benzodiazepine non-responders.[10] The British Association for Psychopharmacology (BAP) consensus guideline lists both ECT and benzodiazepines as first-line treatments, with similar response rates (59–100% for ECT; 66–100% for benzodiazepines in Western studies).[11]
  • Bitemporal placement is generally preferred; no high-quality comparison of electrode placements exists.[10]
  • Many patients benefit from concurrent benzodiazepine maintenance alongside ECT.[10]

3. Treatment-Resistant Depression

  • Health-economic studies suggest ECT may be cost-effective after no more than two medication trials.[2] In a US decision-analytic model, offering ECT after failure of 2 lines of pharmacotherapy and/or psychotherapy (third-line ECT) had an incremental cost-effectiveness ratio of $54,000 per quality-adjusted life-year, below the $100,000 threshold used to define cost-effectiveness. This is modeling evidence, not a guideline threshold.[12]
  • Patients with life-threatening features (suicidality, psychosis, dehydration, malnutrition, catatonia) may receive ECT as primary treatment without serial drug trials.[2]

Efficacy

  • Versus sham and pharmacotherapy: In the UK ECT Review Group meta-analysis, ECT was superior to sham ECT (6 trials, n=256; SES −0.91) and to pharmacotherapy (18 trials, n=1,144; SES −0.80). Bilateral ECT was moderately more effective than unilateral ECT (22 trials, n=1,408; SES −0.32), and high-dose ECT was more effective than low-dose ECT.[13]
  • Treatment-resistant MDD: Pooled response rates are 60–80% and remission rates 50–60%.[2]
  • Speed of response: In the CORE study (n=253; bilateral ECT 3 times weekly), 75% of patients remitted; 34% remitted by ECT #6 (week 2) and 65% by ECT #10 (weeks 3–4), and 54% had a first response by ECT #3 (end of week 1).[14] The mean number of treatments to remission was 7.3 in both CORE and PRIDE phase 1.[15][16]
  • Clinical features associated with high response: psychotic depression and catatonia.[2] Older adults have equal or higher response rates.[17]
  • Suicide and mortality (observational data):
    • A propensity-matched Ontario cohort found no clinically significant increase in serious medical events with ECT and significantly lower suicide death.[18]
    • A propensity-weighted Ontario cohort of psychiatric hospitalizations found ECT associated with about a 50% lower risk of suicide death and a 25% lower risk of all-cause mortality in the year after hospitalization.[19]
    • A VA propensity-matched cohort found no excess mortality after ECT: 30-day all-cause relative odds 1.06 (95% CI 0.65–1.73), and a lower 1-year risk of death from causes other than suicide (RR 0.79, 95% CI 0.66–0.95).[20]
    • A VA propensity-matched cohort (5,157 index ECT courses) found no difference in suicide death at 30 days (RR 0.96) or 1 year (RR 1.38).[21]
    • A 2025 meta-analysis found that suicide outcomes were heterogeneous and did not differ in a consistent direction, whereas all-cause mortality and non-suicide mortality were lower with ECT.[22]
    • A 2026 review of administrative-data studies concluded that, after adjustment for confounding, most studies show no increase in dementia or major cardiovascular events, and that ECT is likely associated with reductions in suicide and all-cause mortality. Unmeasured confounding cannot be excluded.[23]

Technique

  • Anesthesia:
    • ECT is given under general anesthesia with a short-acting IV anesthetic (for example, methohexital, propofol, or etomidate) and a muscle relaxant, typically succinylcholine. Patients are usually not intubated; mask ventilation with oxygen is used. An anticholinergic may be given to limit bradycardia and salivation.[24]
    • Monitoring includes continuous ECG, EEG, pulse oximetry, and blood pressure.[24]
    • Evidence on whether the choice of anesthetic agent affects antidepressant efficacy is uncertain.[5]
  • Pulse width: Brief pulse is 0.5–2.0 ms. Ultrabrief pulse is <0.5 ms (typically 0.25–0.3 ms) and causes fewer cognitive effects.[4]
    • In a meta-analysis (6 studies, n=689), ultrabrief RUL was less effective than brief-pulse RUL and needed more sessions (mean 9.6 vs 8.7).[25]
    • In a double-blind RCT (n=116; twice weekly; 8 times seizure threshold), remission among completers was 68.4% with brief pulse vs 49.0% with ultrabrief pulse. Remission took fewer sessions with brief pulse (7.1 vs 9.2), and cognitive measures did not differ.[26]
    • A 2026 meta-analysis reported pooled remission of 32.2% with ultrabrief high-dose RUL.[27]
  • Electrode placement:
    • Right unilateral (RUL): good efficacy with fewer cognitive effects, but the dose must be clearly suprathreshold; trials used 6 times (PRIDE phase 1) and 8 times (Spaans 2013) seizure threshold.[16][26]
    • Bitemporal (BT): often favored for severe, psychotic, or catatonic presentations and urgent need. Causes more cognitive effects.[10][2]
    • Bifrontal: an alternative placement.
  • Dosing: Empirical stimulus-dose titration at the first session individualizes dosing.[28] EEG monitoring confirms seizure activity and termination.[24]
  • Schedule:
    • Usually 2–3 sessions per week for 6–12 treatments total.[4]
    • Catatonia may need 12 or more sessions. Daily sessions can be used for malignant catatonia or inanition.[10]
    • Continue until remission or plateau. There is no fixed number of treatments.[2]

Pre-ECT Evaluation

  • There are no absolute contraindications.[29]
  • Workup: medical and neurologic history and examination, anesthesia evaluation, and informed consent with capacity assessment. Add cardiology consultation when there are cardiac risk factors or known disease.[2]
  • Higher-risk conditions requiring optimization:
    • Cardiovascular: uncontrolled hypertension, myocardial infarction within 60 days, unstable angina, decompensated heart failure, severe aortic stenosis, uncontrolled atrial fibrillation, unrepaired abdominal aortic aneurysm >5.0 cm, and tachyarrhythmias or bradyarrhythmias causing hypotension or needing urgent care[10]
    • Cerebrovascular: signs of an intracranial lesion (papilledema, focal deficits, mass effect or edema on MRI) and hemorrhagic stroke within 30 days, especially with poorly controlled blood pressure[10]
    • Pheochromocytoma (α- or β-blockade reduces risk)[10]
    • Retinal detachment[3]
    • Intracranial aneurysm or vascular malformation, which requires tight ictal blood pressure control with short-acting β-blockers or calcium-channel blockers[30]
  • Usually safe with precautions: older age, pacemakers and ICDs, and pregnancy.[29]

Concurrent Medication Management

Decisions are individualized. Most psychotropics appear to have little effect on seizure threshold during titration.[31]

Medication class Management
Lithium Combined use was associated with delirium in a US inpatient database: 5.7% vs 0.6% with ECT alone (OR 11.7, 95% CI 7.55–17.99). The delirium rate with combined use was highest in unipolar depression (7.8%).[32] If lithium is continued, Janjua et al. suggest a level of 0.4–0.6 mEq/L for depressed patients, holding the evening and morning doses before each treatment, and monitoring for prolonged post-ECT recovery as an early sign of delirium (expert recommendation, not trial-derived).[28] In PRIDE phase 2, neurocognitive outcomes did not differ between continuation ECT plus venlafaxine–lithium and venlafaxine–lithium alone. Both arms took lithium, so this does not isolate a lithium effect.[33] A 2026 meta-analysis of 11 mostly retrospective studies found a nonsignificant association with confusional states (OR 2.09, 95% CI 0.94–4.66), which became significant with an alternative estimator (OR 2.38). Publication bias suggests the true risk may be underestimated.[34]
Anticonvulsants and benzodiazepines Raise seizure threshold and can cause missed or short seizures; management is individualized.[28]
Exception – catatonia: benzodiazepines are often continued during ECT, and concurrent maintenance can be beneficial; avoid abrupt withdrawal.[10]
Antidepressants Generally well tolerated. Use caution with high-dose venlafaxine or other SNRIs.[28]
Antipsychotics, including clozapine Can be used safely with ECT.[28]

Adverse Effects

  • Mortality:
    • About 2.1 ECT-related deaths per 100,000 treatments in a pooled analysis of 766,180 treatments.[35]
    • In VA data (123,479 treatments), mortality associated with treatment was 3.08 per 10,000 treatments over the first 7 days. The VA study did not attribute deaths to ECT, which explains the difference from the pooled ECT-related estimate.[20]
    • Duma et al. reported all-cause mortality of 0.06 per 1,000 treatments (0.42 per 1,000 patients); 29% of deaths were cardiac.[36]
  • Cardiopulmonary events are the most frequent serious complications (<1% of treatments).[2] Arrhythmia occurs in about 4.66 and acute heart failure in about 2.44 per 1,000 treatments.[36] Other serious events include prolonged apnea, aspiration, and prolonged seizures.[2]
    • Major adverse cardiac events occur in about 1 in 50 patients and after about 1 in 200–500 treatments.[36]
    • In a Swedish propensity-matched cohort of inpatients with depression, ECT was associated with fewer major adverse cardiovascular events at 1 year (1.4% vs 2.3%; HR 0.65).[37]
    • A Danish registry found no higher risk of acute somatic events overall, with the exception of a short-term (0–30 day) cardiac signal in patients without somatic comorbidity, based on few events.[38]
  • Common, self-limited effects: headache, jaw pain, myalgia, nausea, fatigue, and transient postictal confusion.[2]
  • Cognitive effects:[2]
    • Anterograde amnesia usually resolves within 2–4 weeks.
    • Retrograde (autobiographical) amnesia builds over the course and resolves over weeks to months. It persists for more than 1 year in some patients.
    • Delirium is rare and may require pausing or stopping the course.
    • Risk is higher with bitemporal placement, more treatments, and higher charge. Risk is lower with RUL placement, ultrabrief pulse, and shorter courses.
    • Meta-analyses show return to or above baseline in most cognitive domains after more than 1 month.[39]
    • A Danish cohort of 168,015 patients with affective disorders found no increased dementia risk after ECT.[40]
    • The MMSE is insensitive. Assess autobiographical memory, verbal fluency, and verbal memory.[39]

Special Populations

  • Older adults:
    • ECT can be used safely in older adults.[29] Response rates are equal or higher.[17]
    • In PRIDE phase 1 (n=240, age ≥60), RUL ultrabrief ECT at 6 times seizure threshold plus venlafaxine gave 61.7% intention-to-treat remission and 70% response.[16]
    • In a matched US Medicare cohort (n=41,620), ECT was associated with lower 1-year all-cause mortality (adjusted HR 0.61, 95% CI 0.56–0.66). Suicide risk was lower through 3 months after discharge (HR 0.56 at 3 months) but not at 6 months (HR 0.87) or 12 months (HR 0.92). This finding is observational and subject to residual confounding.[41]
    • In an Ontario population cohort (8,810 patients, 135,831 treatments), falls (2.7 per 10,000 treatments) and pneumonia (1.8 per 10,000) were the most common medical events. Seven-day mortality in patients aged 65 and older (0.7 per 10,000 treatments) was 3–5 times lower than after ambulatory surgery in the same age group.[42]
  • Pregnancy:
    • There are no RCTs. A systematic review of 45 case reports and case series (130 pregnant women) found ECT relatively safe and effective, with most complications low or moderate grade. Transient fetal heart rate changes and uterine contractions were the most frequent low-grade complications, and preterm birth was the most frequent moderate-grade complication.[43] Earlier reviews of the case literature also describe fetal bradyarrhythmia, abdominal pain, vaginal bleeding, placental abruption, and threatened abortion, often mild and transient; attributing these events to ECT is difficult.[11]
    • Decisions about ECT in pregnancy should involve clinicians with expertise in ECT, perinatal psychiatry, and obstetrics.[3][11]
    • The American Psychiatric Association and the American College of Obstetricians and Gynecologists have jointly endorsed ECT as safe and effective for refractory depression in pregnancy. Risks include aspiration and failed or traumatic intubation (airway edema, reduced lower esophageal sphincter tone) and reduced uteroplacental perfusion. Nonsustained fetal heart rate abnormalities are the most common adverse outcome; limited data show no increase in placental abruption, preterm delivery, prolonged fetal heart rate abnormalities, or stillbirth.[44]
    • Precautions: withhold nonessential anticholinergic medications and give a nonparticulate antacid before treatment; left lateral uterine displacement (for example, a wedge under the right hip) after 20 weeks' gestation; fetal heart rate monitoring before and after treatment, with continuous fetal monitoring if the pregnancy is late term or high risk; pre-oxygenate but avoid excess hyperventilation; if maternal bradycardia needs treatment, use glycopyrrolate, because atropine crosses the placenta.[44][45] Fetal monitoring recommendations vary by gestational age and between protocols.
    • Airway management differs between sources: Jones et al. advise avoiding intubation if possible, whereas the Ward protocol recommends intubation, especially after the first trimester.[44][45]
    • In a Swedish national registry study (97 pregnancies), no severe adverse events were directly linked to ECT, and the response rate was 74%. Preterm birth was more common than in matched pregnant women who did not receive ECT but similar to the same women's other pregnancies without ECT, suggesting confounding by illness severity.[46]
  • Adolescents (13 years and older): Included in the FDA indication. AACAP and RANZCP support ECT for severe affective or psychotic illness or catatonia after pharmacologic failure.[4]

Continuation and Maintenance ECT (Relapse Prevention)

  • In a 24-week RCT after successful ECT, relapse was 84% on placebo, 60% on nortriptyline, and 39% on nortriptyline plus lithium. All but one relapse on nortriptyline–lithium occurred within 5 weeks of stopping ECT.[47]
  • Even with continuation pharmacotherapy, 51.1% relapse by 12 months, most (37.7%) within the first 6 months. The 6-month relapse rate with continuation ECT was similar (37.2%). Continuation treatment should therefore start immediately.[48]
  • VA/DoD: follow ECT with antidepressant maintenance, or with repeated ECT if antidepressants are not tolerated.[3]
  • Trials:
    • CORE: continuation ECT was equivalent to lithium plus nortriptyline. Only about 46% of each arm remained relapse-free at 6 months.[49]
    • PRIDE (n=120 older adult remitters): four continuation ECT sessions plus as-needed ECT (STABLE algorithm), added to venlafaxine plus lithium, gave lower HAM-D scores at 24 weeks than medication alone (adjusted difference 4.2 points, 95% CI 1.6–6.9). Relapse was 13.1% vs 20.3%, and MMSE did not differ.[50]
  • Meta-analytic data:
    • Continuation/maintenance ECT (C/M-ECT) plus pharmacotherapy reduced relapse versus pharmacotherapy alone: RR 0.64 (95% CI 0.41–0.98) at 6 months and RR 0.46 (95% CI 0.21–0.98) at 1 year (5 RCTs). The authors described the evidence as preliminary and limited.[51]
    • A 2025 meta-analysis of 4 RCTs (n=254) found that continuation ECT plus pharmacotherapy reduced 6-month relapse compared with pharmacotherapy alone (RR 0.57, 95% CI 0.37–0.88; number needed to treat 7), with similar all-cause dropout (RR 1.12, 95% CI 0.48–2.62).[52]
  • Registry data (observational):
    • In a Danish nationwide cohort of ECT-treated patients, C/M-ECT was associated with lower hospitalization after the acute course (incidence rate ratio 0.51, 95% CI 0.41–0.62). The cohort included all diagnoses, with more patients with schizophrenia or schizoaffective disorder, so the findings are not MDD-specific.[53]
    • In a Swedish register study of MDD (27,851 patients), continuation ECT after discharge was associated with lower psychiatric readmission at 30 days (OR 0.54, 95% CI 0.42–0.70) and 90 days (OR 0.61, 95% CI 0.50–0.74). Few patients received continuation ECT and they likely differed from other patients, so the authors called for further study.[54]
  • 2026 global Delphi consensus (expert opinion; 18 international ECT experts, consensus defined as ≥80% agreement):[55]
    • Give all patients lithium plus an antidepressant (TCA, venlafaxine, or a previously effective agent).
    • Taper C/M-ECT rather than stopping abruptly in patients at high relapse risk and in those with severe or psychotic depression.
    • Use psychotherapy as an adjunct only.
    • No consensus was reached on rTMS, esketamine, or treatment duration beyond 6 months.

References

  1. ↑ US Food and Drug Administration. Neurological Devices; Reclassification of Electroconvulsive Therapy Devices; Effective Date of Requirement for Premarket Approval for Electroconvulsive Therapy for Certain Specified Intended Uses. Final order. Fed Regist. 2018;83:66103-66124.
  2. ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 Espinoza RT, Kellner CH (2022). "Electroconvulsive Therapy". N Engl J Med. 386 (7): 667–672. doi:10.1056/NEJMra2034954.
  3. ↑ 3.0 3.1 3.2 3.3 US Department of Veterans Affairs and Department of Defense. VA/DoD Clinical Practice Guideline for the Management of Major Depressive Disorder, Version 4.0. 2022. Guideline page
  4. ↑ 4.0 4.1 4.2 4.3 Munkholm K, Jørgensen KJ, Paludan-Müller AS. Electroconvulsive therapy for depression (protocol). Cochrane Database Syst Rev. 2021.
  5. ↑ 5.0 5.1 Munkholm K, Jørgensen KJ, Paludan-Müller AS. Electroconvulsive therapy for preventing relapse and recurrence in people with depression (protocol). Cochrane Database Syst Rev. 2022.
  6. ↑ Lam RW, Kennedy SH, Adams C; et al. (2024). "Canadian Network for Mood and Anxiety Treatments (CANMAT) 2023 Update on Clinical Guidelines for Management of Major Depressive Disorder in Adults". Can J Psychiatry. 69 (9): 641–687. doi:10.1177/07067437241245384. PMID 38711351 Check |pmid= value (help).
  7. ↑ Coles S, Wise D. Management of Major Depressive Disorder in Adults: Guidelines From CANMAT. Am Fam Physician. 2025;112(4):458-461.
  8. ↑ McQuaid JR, Buelt A, Capaldi V, et al. The Management of Major Depressive Disorder: Synopsis of the 2022 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline. Ann Intern Med. 2022;175(10):1440-1451. doi:10.7326/M22-1603.
  9. ↑ Kellner CH, Obbels J, Sienaert P. When to consider electroconvulsive therapy (ECT). Acta Psychiatr Scand. 2020;141(4):304-315. doi:10.1111/acps.13134.
  10. ↑ 10.00 10.01 10.02 10.03 10.04 10.05 10.06 10.07 10.08 10.09 Wilson JE, Oldham MA, Francis A, et al. American Psychiatric Association Resource Document on Catatonia. 2025. APA
  11. ↑ 11.0 11.1 11.2 11.3 Rogers JP, Oldham MA, Fricchione G, et al. Evidence-based consensus guidelines for the management of catatonia: recommendations from the British Association for Psychopharmacology. J Psychopharmacol. 2023;37(4):327-369. doi:10.1177/02698811231158232.
  12. ↑ Ross EL, Zivin K, Maixner DF. Cost-effectiveness of electroconvulsive therapy vs pharmacotherapy/psychotherapy for treatment-resistant depression in the United States. JAMA Psychiatry. 2018;75(7):713-722. doi:10.1001/jamapsychiatry.2018.0768.
  13. ↑ UK ECT Review Group. Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis. Lancet. 2003;361(9360):799-808.
  14. ↑ Husain MM, Rush AJ, Fink M; et al. (2004). "Speed of response and remission in major depressive disorder with acute electroconvulsive therapy (ECT): a Consortium for Research in ECT (CORE) report". J Clin Psychiatry. 65 (4): 485–491. PMID 15119910.
  15. ↑ Hart KL, McCoy TH, Henry ME, Seiner SJ, Luccarelli J. Factors associated with early and late response to electroconvulsive therapy. Acta Psychiatr Scand. 2023;147(4):322-332. doi:10.1111/acps.13537.
  16. ↑ 16.0 16.1 16.2 Kellner CH, Husain MM, Knapp RG; et al. (2016). "Right Unilateral Ultrabrief Pulse ECT in Geriatric Depression: Phase 1 of the PRIDE Study". Am J Psychiatry. 173 (11): 1101–1109. PMID 27418379.
  17. ↑ 17.0 17.1 Marx W, Penninx BWJH, Solmi M; et al. (2023). "Major depressive disorder". Nat Rev Dis Primers. 9: 44. doi:10.1038/s41572-023-00454-1.
  18. ↑ Kaster TS, Vigod SN, Gomes T; et al. (2021). "Risk of serious medical events in patients with depression treated with electroconvulsive therapy: a propensity score-matched, retrospective cohort study". Lancet Psychiatry. 8 (8): 686–695. doi:10.1016/S2215-0366(21)00168-1.
  19. ↑ Kaster TS, Blumberger DM, Gomes T, et al. Risk of suicide death following electroconvulsive therapy treatment for depression: a propensity score-weighted, retrospective cohort study in Canada. Lancet Psychiatry. 2022;9(6):435-446. doi:10.1016/S2215-0366(22)00077-3.
  20. ↑ 20.0 20.1 Watts BV, Peltzman T, Shiner B (2021). "Mortality after electroconvulsive therapy". Br J Psychiatry. 219 (5): 588–593. doi:10.1192/bjp.2021.63.
  21. ↑ Watts BV, Peltzman T, Shiner B (2022). "Electroconvulsive therapy and death by suicide". J Clin Psychiatry. 83 (3): 21m13886. doi:10.4088/JCP.21m13886.
  22. ↑ Naismith H, Wilson J, Costello H; et al. (2025). "Systematic review and meta-analysis of the effectiveness of ECT in reducing suicidal ideation, self-harm, suicide, and mortality". Psychol Med. 55: e328. doi:10.1017/S0033291725102183.
  23. ↑ Kaster TS, Rhee TG, Adler E, Kirov G. Electroconvulsive therapy: improved understanding of long-term risks and benefits from advances in administrative health data. Br J Psychiatry. 2026. doi:10.1192/bjp.2026.10613.
  24. ↑ 24.0 24.1 24.2 Tess AV, Smetana GW (2009). "Medical evaluation of patients undergoing electroconvulsive therapy". N Engl J Med. 360 (14): 1437–1444. doi:10.1056/NEJMra0707755.
  25. ↑ Tor PC, Bautovich A, Wang MJ; et al. (2015). "A Systematic Review and Meta-Analysis of Brief Versus Ultrabrief Right Unilateral Electroconvulsive Therapy for Depression". J Clin Psychiatry. 76 (9): e1092–e1098. PMID 26213985.
  26. ↑ 26.0 26.1 Spaans HP, Verwijk E, Comijs HC; et al. (2013). "Efficacy and cognitive side effects after brief pulse and ultrabrief pulse right unilateral electroconvulsive therapy for major depression: a randomized, double-blind, controlled study". J Clin Psychiatry. 74 (11): e1029–e1036.
  27. ↑ Jelovac A, McLoughlin DM. Ultrabrief pulse electroconvulsive therapy for depression: a systematic review and meta-analysis. Mol Psychiatry. 2026.
  28. ↑ 28.0 28.1 28.2 28.3 28.4 Janjua AU, Dhingra AL, Greenberg R, McDonald WM. The Efficacy and Safety of Concomitant Psychotropic Medication and Electroconvulsive Therapy (ECT). CNS Drugs. 2020;34(5):509-520. doi:10.1007/s40263-020-00729-1. PMID 32342484.
  29. ↑ 29.0 29.1 29.2 Lisanby SH (2007). "Electroconvulsive Therapy for Depression". N Engl J Med. 357 (19): 1939–1945. doi:10.1056/NEJMct075234. PMID 17989386.
  30. ↑ Mehdi SMA, Devanand DP. Electroconvulsive therapy in elderly patients with cerebral aneurysms: a systematic review with clinical recommendations. J Geriatr Psychiatry Neurol. 2021;34(6):504-512. doi:10.1177/08919887211039016.
  31. ↑ Chiao S, Isenberg K, North CS. Psychotropic medication effects on seizure threshold and seizure duration during electroconvulsive therapy stimulus titration. J ECT. 2020;36(2):115-122. doi:10.1097/YCT.0000000000000621.
  32. ↑ Patel RS, Bachu A, Youssef NA (2020). "Combination of Lithium and Electroconvulsive Therapy (ECT) Is Associated With Higher Odds of Delirium and Cognitive Problems in a Large National Sample Across the United States". Brain Stimul. 13 (1): 15–19. doi:10.1016/j.brs.2019.08.012. PMID 31492631.
  33. ↑ Lisanby SH, McClintock SM, McCall WV; et al. (2022). "Longitudinal Neurocognitive Effects of Combined Electroconvulsive Therapy (ECT) and Pharmacotherapy in Major Depressive Disorder in Older Adults: Phase 2 of the PRIDE Study". Am J Geriatr Psychiatry. 30 (1): 15–28. PMID 34074611 Check |pmid= value (help).
  34. ↑ Van den Eynde L, Takamiya A, Vansteelandt K, et al. Lithium, Electroconvulsive Therapy and Cognition: A Systematic Review and Meta-Analysis. Acta Psychiatr Scand. 2026;154(2):116-130. doi:10.1111/acps.70095.
  35. ↑ Tørring N, Sanghani SN, Petrides G, Kellner CH, Østergaard SD (2017). "The mortality rate of electroconvulsive therapy: a systematic review and pooled analysis". Acta Psychiatr Scand. 135 (5): 388–397. doi:10.1111/acps.12721.
  36. ↑ 36.0 36.1 36.2 Duma A, Maleczek M, Panjikaran B; et al. (2019). "Major Adverse Cardiac Events and Mortality Associated with Electroconvulsive Therapy: A Systematic Review and Meta-analysis". Anesthesiology. 130 (1): 83–91. PMID 30557212.
  37. ↑ Nordenskjöld A, Güney P, Nordenskjöld AM (2022). "Major adverse cardiovascular events following electroconvulsive therapy in depression: a register-based nationwide Swedish cohort study with 1-year follow-up". J Affect Disord. 296: 298–304. PMID 34606801 Check |pmid= value (help).
  38. ↑ Osler M, Rozing MP, Jorgensen MB, Jorgensen A (2022). "Mortality and acute somatic events following electroconvulsive therapy in patients with pre-existing somatic comorbidity: a register-based nationwide Danish cohort study". World J Biol Psychiatry. 23 (4): 318–326. doi:10.1080/15622975.2021.1995808. PMID 34668447 Check |pmid= value (help).
  39. ↑ 39.0 39.1 Landry M, Moreno A, Patry S, Potvin S, Lemasson M (2021). "Current practices of electroconvulsive therapy in mental disorders: a systematic review and meta-analysis of short and long-term cognitive effects". J ECT. 37 (2): 119–127. doi:10.1097/YCT.0000000000000723.
  40. ↑ Osler M, Rozing MP, Christensen GT, Andersen PK, Jørgensen MB. Electroconvulsive therapy and risk of dementia in patients with affective disorders: a cohort study. Lancet Psychiatry. 2018;5(4):348-356.
  41. ↑ Rhee TG, Sint K, Olfson M, et al. Association of electroconvulsive therapy with risks of all-cause mortality and suicide in older Medicare patients. Am J Psychiatry. 2021;178(12):1089-1097. doi:10.1176/appi.ajp.2021.21040351.
  42. ↑ Blumberger DM, Seitz DP, Herrmann N, et al. Low medical morbidity and mortality after acute courses of electroconvulsive therapy in a population-based sample. Acta Psychiatr Scand. 2017;136(6):583-593. doi:10.1111/acps.12815.
  43. ↑ Cipolla S, Catapano P, Messina M, Pezzella P, Giordano GM. Safety of electroconvulsive therapy (ECT) in pregnancy: a systematic review of case reports and case series. Arch Womens Ment Health. 2024;27(2):157-178. doi:10.1007/s00737-023-01394-1.
  44. ↑ 44.0 44.1 44.2 Jones SI, Boettcher LB, Kuller JA. Perinatal depression (letter). JAMA. 2026;335(14):1269. doi:10.1001/jama.2026.0100.
  45. ↑ 45.0 45.1 Ward HB, Fromson JA, Cooper JJ, De Oliveira G, Almeida M. Recommendations for the use of ECT in pregnancy: literature review and proposed clinical protocol. Arch Womens Ment Health. 2018;21(6):715-722. doi:10.1007/s00737-018-0851-0.
  46. ↑ Arnison T, Rask O, Nordenskjöld A, Movahed Rad P. Safety of and response to electroconvulsive therapy during pregnancy: results from population-based nationwide registries. Acta Psychiatr Scand. 2024;150(5):360-371. doi:10.1111/acps.13623.
  47. ↑ Sackeim HA, Haskett RF, Mulsant BH, et al. Continuation pharmacotherapy in the prevention of relapse following electroconvulsive therapy: a randomized controlled trial. JAMA. 2001;285(10):1299-1307. doi:10.1001/jama.285.10.1299.
  48. ↑ Jelovac A, Kolshus E, McLoughlin DM. Relapse following successful electroconvulsive therapy for major depression: a meta-analysis. Neuropsychopharmacology. 2013;38(12):2467-2474.
  49. ↑ Kellner CH, Knapp RG, Petrides G; et al. (2006). "Continuation electroconvulsive therapy vs pharmacotherapy for relapse prevention in major depression: a multisite study from the Consortium for Research in Electroconvulsive Therapy (CORE)". Arch Gen Psychiatry. 63 (12): 1337–1344. doi:10.1001/archpsyc.63.12.1337.
  50. ↑ Kellner CH, Husain MM, Knapp RG, et al. A Novel Strategy for Continuation ECT in Geriatric Depression: Phase 2 of the PRIDE Study. Am J Psychiatry. 2016;173(11):1110-1118. PMID 27418381.
  51. ↑ Elias A, Phutane VH, Clarke S, Prudic J (2018). "Electroconvulsive therapy in the continuation and maintenance treatment of depression: systematic review and meta-analyses". Aust N Z J Psychiatry. 52 (5): 415–424. PMID 29256252.
  52. ↑ Jelovac A, Braithwaite R, Kellner CH, McLoughlin DM. Continuation electroconvulsive therapy combined with pharmacotherapy for depression relapse prevention: a systematic review and meta-analysis. Psychol Med. 2025;55:e251. doi:10.1017/S0033291725101608.
  53. ↑ Jørgensen A, Gronemann FH, Rozing MP, Jørgensen MB, Osler M. Clinical outcomes of continuation and maintenance electroconvulsive therapy. JAMA Psychiatry. 2024;81(12):1207-1214. doi:10.1001/jamapsychiatry.2024.2360.
  54. ↑ Stenmark L, Kellner CH, Landén M, et al. Electroconvulsive therapy and psychiatric readmission in major depressive disorder: a population-based register study. Acta Psychiatr Scand. 2021. doi:10.1111/acps.13373.
  55. ↑ Rovers JJE, van Eijndhoven PFP, Abbott C, et al. A Global Delphi-Based Expert Consensus on Relapse Prevention Strategies Following Successful Electroconvulsive Therapy for Major Depressive Disorder. Am J Psychiatry. 2026;183(6):401-408. doi:10.1176/appi.ajp.20250641.
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