Electroconvulsive Therapy (ECT) from the late 1930s, was the first reliable and effective treatment for major depressive disorder and acute schizophrenia. It was life-saving for many, and allowed other patients’ discharge from hospital rather than spending years as inpatients. However, there were major adverse events as ECT was initially used. The latter included severe confusion and memory problems from the stimulus techniques used and occasional fractures from violent tonic movements with treatment. Training was rudimentary or non-existent. Treatment evolution with square-wave stimuli and the use of anaesthetics and muscle relaxants provided improved outcomes with fewer adverse events. The introduction of effective antipsychotics and antidepressants from the 1950s led to a view that ECT was an old-fashioned and redundant treatment. It was targeted by the anti-psychiatry movement in the 1960s and 1970s and banned in many jurisdictions, or subject to stringent legislative control.

The recognition that many patients remained “treatment resistant” to pharmacotherapy, yet responded to ECT, has led to a resurgence of ECT.
There are now multiple ECT techniques. These involve better patient assessment for suitability for ECT, anaesthetics administered by consultant anaesthetists and the use of ultra-brief square-wave stimuli in computer-controlled constant-current machines. Individual dose titration, electroencephalogram (EEG) monitoring, with trained psychiatrists administering ECT in better equipped facilities has resulted in a resurgence in the use of ECT with improved patient outcomes, and the potential for minimal adverse events and better patient acceptance.

The evolution of ECT and future options will be reviewed and discussed.