Electroconvulsive therapy (ECT), also known as electroshock, is a well established, albeit controversial, psychiatric treatment in which seizures are electrically induced in anesthetized patients for therapeutic effect. Today, ECT is most often used as a treatment for severe major depression which has not responded to other treatment, and is also used in the treatment of mania (often in bipolar disorder), catatonia and schizophrenia. It was first introduced in the 1930s and gained widespread use as a form of treatment in the 1940s and 1950s; today, an estimated 1 million people worldwide receive ECT every year, usually in a course of 6–12 treatments administered 2 or 3 times a week.

Electroconvulsive therapy can differ in its application in three ways: electrode placement, length of time that the stimulus is given, and the property of the stimulus. The variance of these three forms of application have significant differences in both adverse side effects and positive outcomes. In a study, ECT was shown clinically to be the most effective treatment for severe depression, and to result in improved quality of life in both short- and long-term.After treatment, drug therapy can be continued, and some patients receive continuation/maintenance ECT. However that study is contradicted by other studies referenced in this article. The American Psychiatric Association and the British National Institute for Health and Clinical Excellence have concluded that the procedure does not cause brain damage in adults.[5][6] Certain types of ECT have been shown to cause persistent memory loss whereas confusion usually clears within hours of treatment. Informed consent is a standard of modern electroconvulsive therapy. Involuntary treatment is uncommon in countries that follow contemporary standards and is typically only used when the use of ECT is believed to be potentially life saving.

Indications

There is considerable variability among practitioners in the frequency with which ECT is used as first-line/primary treatment or is only considered for secondary use after patients have not responded to other interventions.[10]

The APA 2001 guidelines give the primary indications for ECT among patients with depression as a lack of a response to, or intolerance of, antidepressant medications; a good response to previous ECT; and the need for a rapid and definitive response (e.g. because of psychosis or a risk of suicide). The decision to use ECT depends on several factors, including the severity and chronicity of the depression, the likelihood that alternative treatments would be effective, the patient's preference, and a weighing of the risks and benefits.

Some guidelines recommend that cognitive behavioral therapy or other psychotherapy should generally be tried before ECT is used. However, treatment resistance is widely defined as lack of therapeutic response to two antidepressants. The APA states that at times patients will prefer to receive ECT over alternative treatments, but commonly the opposite will be the case.

The APA ECT guidelines state that severe major depression with psychotic features, manic delirium, or catatonia are conditions for which there is a clear consensus favoring early reliance on ECT. The NICE guidelines recommend ECT for patients with severe depression, catatonia, or prolonged or severe mania.

The 2001 APA guidelines support the use of ECT for relapse prevention, but the 2003 NICE guidelines do not.

The 2001 APA ECT guidelines say that ECT is rarely used as a first-line treatment for schizophrenia but is considered after unsuccessful treatment with antipsychotic medication, and may also be considered in the treatment of patients with schizoaffective or schizophreniform disorder. The 2003 NICE ECT guidelines do not recommend ECT for Schizophrenia.

The NICE 2003 guidelines state that doctors should be particularly cautious when considering ECT treatment for women who are pregnant and for older or younger people, because they may be at higher risk of complications with ECT. The 2001 APA ECT guidelines say that ECT may be safer than alternative treatments in the infirm elderly and during pregnancy, and the 2000 APA depression guidelines stated that the literature supports the safety for mother and fetus, as well as the efficacy during pregnancy.

Non-clinical patient characteristics

About 70 percent of ECT patients are women. This is largely, but not entirely, due to the fact that women are more likely to receive treatment for depression. Older and more affluent patients are also more likely to receive ECT. The use of ECT treatment is "markedly reduced for ethnic minorities."

Effectiveness

In the US the 1999 Surgeon General's report on mental health summarised psychiatric opinion at the time about the effectiveness of ECT. It stated that both clinical experience and controlled trials had determined ECT to be effective (with an average 60 to 70 percent remission rate) in the treatment of severe depression, some acute psychotic states, and mania. Its effectiveness had not been demonstrated in dysthymia, substance abuse, anxiety, or personality disorder. The report stated that ECT does not have a long-term protective effect against suicide and should be regarded as a short-term treatment for an acute episode of illness, to be followed by continuation therapy in the form of drug treatment or further ECT at weekly to monthly intervals.A 2004 large multicentre clinical follow-up study of ECT patients in New York – describing itself as the first systematic documentation of the effectiveness of ECT in community practice in the 65 years of its use – found remission rates of only 30–47 percent, with 64 percent of those relapsing within six months. A survey of New York psychiatrists found that they thought that 85 percent of their patients benefited from ECT.

In the UK in 2003 the UK ECT Review Group, led by Professor Geddes of Oxford University, reviewed the evidence and concluded that ECT had been shown to be an effective short-term treatment for depression (as measured by symptom rating scales) in physically healthy adults, and that it was probably more effective than drug treatment. Bilateral ECT was more effective than unilateral, and high-dose was more effective than low-dose. Their conclusions were qualified: most of the trials were old and conducted on small numbers of patients; some groups (for example, elderly people, women with postpartum depression and people with treatment-resistant depression) were under-represented in the trials even though ECT is believed to be especially effective for them.

ECT on its own does not usually have a sustained benefit – virtually all those who remit end up relapsing within 6 months following a course, even when given a placebo. The relapse rate in the first six months may be reduced by the use of psychatric medications or further ECT, but remains high.

Administration

Informed consent is sought before treatment. Patients are informed about the risks and benefits of the procedure. Patients are also made aware of risks and benefits of other treatments and of not having the procedure done at all. Depending on the jurisdiction the need for further inputs from other medical professionals or legal professionals may be required. ECT is usually given on an in-patient basis. Prior to treatment a patient is given a short-acting anesthetic such as methohexital, propofol, etomidate a muscle relaxant such as suxamethonium (succinylcholine), and occasionally atropine to inhibit salivation.

Electrodes can be placed one on either side of the patient's head. This is known as unilateral ECT. Unilateral ECT is 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. 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.[12] 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.[23] 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.[17] 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.

ECT machines

Most modern ECT machines 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. Typically, the electrical stimulus used in ECT is about 800 milliamps, and the current flows for between one and 6 secondsIn the USA, ECT machines are manufactured by two companies, Somatics, which is owned by psychiatrists Richard Abrams and Conrad Swartz, and Mecta. The Food and Drug Administration has classified the devices used to administer ECT as Class III medical devices. Class III is the highest-risk class of medical devices. In the UK the market for ECT machines was long monopolised by Ectron Ltd, although in recent years some hospitals have started using American machines. Ectron Ltd was set up by psychiatrist Robert Russell, who together with a colleague from the Three Counties Asylum, Bedfordshire, invented the Page–Russell technique of intensive ECT.

[edit] Variations in international practice

There is wide variation in ECT use between different countries, different hospitals, and different psychiatrists.[12] 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.[25] Guidelines on the use of ECT are stringent in the USA and the UK. Modern standards are not always followed throughout the world and not all countries that use ECT have written technical standards. The use of both anesthesia and muscle relaxants is universally recommended in the administration of ECT. If anesthesia and muscle relaxants are not used the procedure is called unmodified ECT. In a minority of countries such as Japan,[26] India,[27] and Nigeria,[28] ECT may be used without anesthesia. WHO has called for a world wide ban on unmodified ECT and the topic is currently being debated in countries like India. The practice has been recently abolished in Turkey's largest psychiatric hospital. A major difficulty for developing countries in eliminating unmodified ECT is a lack of trained anesthesiologists available to administer the procedure.[ A small minority of countries never seek consent before administering ECT. This significantly uneven application of ECT around the world continues to make ECT a controversial procedure.

In the USA, 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. 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 1,500 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. As of 2007, electroconvulsive therapy practice is not officially regulated in the USA, and the education of physicians in its prescription and administration has been described] as poor. 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[35][36] to about 12,000 per annum. 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 Clinical Excellence, a government body which was set up to standardize treatment throughout the National Health Service, 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 got 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.

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 Holland and Italy, where its use is severely restricted".

Adverse effects

The physical risks of ECT are similar to those of brief general anesthesia; the United States' Surgeon General's report says that there are "no absolute health contraindications" to its use. Immediately following treatment the most common adverse effects are confusion and memory loss. The state of confusion usually disappears after a few hours.

Effects on cognition and memory

It is the effects of ECT on long-term memory that give rise to much of the concern surrounding its use.The acute effects of ECT 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 sine-wave rather than brief-pulse currents. The vast majority of modern treatment uses brief pulse currents. Research by Harold Sackeim has shown that excessive current causes more risk for memory loss, and shocking only the right side of the head protects the left side, which contains the brain's verbal structure. 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 of memories in the weeks prior to the treatment.Later research by the same author suggested memory of events in the months prior to treatment might be lost, as well as suggesting that self-report of memory loss was in fact a problem before treatment which patients associated with it.[Further reviews have supported the idea that reports of memory loss are due to somatoform disorders and not to brain damage 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 review of patient self-reporting found that between 29 percent and 55 percent (depending on the study) of people who had undergone ECT reported persistent memory loss. In 2000 American psychiatrist Sarah Lisanby and colleagues found that bilateral ECT left patients with persistent impairment for memory of public events" as compared to RUL ECT. A large study (250 subjects), published January 2007 by Sackeim and colleagues found that some forms (namely bilateral application and sine wave currents) of ECT "routine[ly]" causes "adverse cognitive effects," including cognitive dysfunction and memory loss, that can persist for an extended period The same study determined that the cognitive deficits produced by ECT were more pronounced in women than in men. Formal neuropsychological testing has documented permanent neuropsychological deficits in patients who receive certain types of ECT treatment, A recent article by a neuropsychologist and a psychiatrist in Dublin suggests that ECT patients who experience cognitive problems following ECT should be offered some form of cognitive rehabilitation. The authors say that the failure to attempt to rehabilitate patients may be partly responsible for the negative public image of ECT.

A study published in 2004 in the Journal of Mental Health reported that 35 to 42% of patients said ECT resulted in loss of intelligence The study also reported, "There is no overlap between clinical and consumer studies on the question of benefit."

Effects on brain structure

A number of national mental health institutions have concluded that there is no evidence that ECT causes structural brain damage in adults. A 1999 report by the United States Surgeon General stated, "The fears that ECT causes gross structural brain pathology have not been supported by decades of methodologically sound research in both humans and animals".All of the recent scientific reviews on this topic which reviewed the body of ECT research using autopsies, brain imaging, and animal studies of electroconvulsive therapy, have also concluded that there is no evidence that ECT causes brain damage Current research is examining the possibility that, "...rather than cause brain damage, there is evidence that ECT may reverse some of the damaging effects of serious psychiatric illness"[] However, as of 2003 there had been no studies on the impact of ECT on the developing brain A 2007 study by Sackeim et al. found that ECT results in widespread, persisting, generalized cognitive dysfunction, which would seem to support claims that ECT causes brain damage.[ Evidence of brain damage following shock have been demonstrated by a number of large animal studies, human autopsy studies, brain wave studies, and CT scan studies. In particular, animal and human autopsy studies have shown that shock routinely causes ‘widespread pinpoint hemorrhages and scattered cell death.’

While the damage can be found throughout the brain, it is often worst beneath the electrodes. Since at least one electrode always lies over the frontal lobe, it is no exaggeration to call electroshock an electrical lobotomy.

Peter R. Breggin, Brain Disabling Treatments in Psychiatry: Drugs, Electroshock, and the Psychopharmaceutical Complex

The 1990 APA task force report on ECT has ignored much of the scientific literature pointing out the negative effects of electroshock therapy. In 1952 Hans Hartelius conducted and published an animal study on cats entitled "Cerebral Changes Following Electrically Induced Convulsions" in which a double-blind microscopic pathology examination showed that it was possible to distinguish between the 8 shocked animals from the 8 non-shocked animals with remarkable accuracy based on statistically significant structural changes to the brain, including vessel wall changes, gliosis, and nerve cell changes. Based on the detection of shadow cells and neuronophagia, Hartelius determined that there was indeed irreversible damage on nerve cells associated with ECT.A similar study had also been conducted in 1946 on rhesus monkeys using short courses of electroshock with the minimal current required to induce convulsions (much less than is used in modern ECT). The study found microscopic evidence of "rarefaction" (cell loss) in the cerebral cortex after only 4 ECT, and after 12 ECT another subject showed small areas of rarefaction and other evidence of cell deterioration and death. Numerous other studies between 1942 and 1949 on both humans and animals have found similar findings but were all left out of the 1990 APA report.

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[60][61][62]. 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 Much of the medical literature in this area is composed of case studies of single or twin pregnancies, and although some have reported serious complications the majority have found ECT to be safe

Mechanism of action

The aim of ECT is to induce a therapeutic clonic seizure (a seizure where the person loses consciousness and has convulsions) lasting for at least 15 seconds. Although a large amount of research has been carried out, the exact mechanism of action of ECT remains elusive. The main reasons for this are the difficulty of isolating the therapeutic effect from the plethora of effects that accompany the anesthetic, electric shock and seizure; the differences between the brains of humans and those of other animals; and the lack of satisfactory animal models of mental illness.

Electroconvulsive Therapy (ECT) increases serum brain-derived neurotrophic factor (BDNF) in drug resistant depressed patients.

Legal status

Informed consent

It is widely acknowledged internationally that written informed consent is as important in ECT as other medical treatments. The World Health Organization, in its 2005 publication "Human Rights and Legislation WHO Resource Book on Mental Health," specifically states, "ECT should be administered only after obtaining informed consent."

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 the treatment may be revoked at anytime during a course of ECT. The Surgeon General's report on mental health said 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 advised 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 would be required to fully satisfy the legal obligation for 'informed consent', one psychiatrist, working for an antipsychiatry organisation, has formulated his own 'consent form'] using the Texas Legislature as a model.[Some question the effects of drugs on the ability to give 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.

Involuntary ECT

Procedures for involuntary ECT vary from country to country depending on local mental health laws. Legal proceedings are required in some countries, while in others ECT is seen as another form of treatment that may be given involuntarily as long as legal conditions are observed.

In the USA, the Surgeon General's report on mental health requires a judicial proceeding, at which patients may be represented by legal counsel, prior to initiation of involuntary ECT, stating: "As a rule, the law requires that such petitions are granted only where the prompt institution of ECT is regarded as potentially lifesaving, as in the case of a person in grave danger because of lack of food or fluid intake caused by catatonia."However, there are legal loopholes that thwart strict adherence to this principle.

For example, an American citizen is currently being forced to undergo ECT against his will, even though his life is not in danger.  In this March 17, 2009 video, the man, his mother, and advocates, speak out against his forced ECT. The description of the video states that "Though Sandford, 54, is not charged with any crime, he has received over 40 such rounds of shocks on an outpatient basis so far – even after his original mental problems have long since subsided and he has repeatedly asked for the shocks to stop. Over the objections of Sandford, his mother and friends, his legal conservator at Lutheran Social Service of MN (LSSMN) has gone to court and succeeded in mandating a continuation of the procedure." The TCIMC reports that "Like all other USA states, Minnesota has [legal] loopholes allowing [its] citizens to receive electroshock over their expressed wishes." 

In England and Wales the Mental Health Act 1983 currently allows the use of ECT on detained patients (with and without capacity) if the treatment is likely to alleviate or prevent deterioration in a condition and is authorized by a psychiatrist from the Mental Health Act Commission's panel. However, proposed amendments to the Mental Health Act (clause 30) will introduce a capacity-threshold for the imposition of ECT. This in effect will mean that ECT may not be given to a patient who has capacity to refuse to consent to it, irrespective of his or her detention under the Act (the treatment may still be given in an emergency under s62). If the treating psychiatrist thinks the need for treatment is urgent they may start a course of ECT before authorization.About 2,000 people a year in England and Wales are treated without their consent under the Mental Health Act, with a small number of informal patients treated in this way under common law. In Scotland the Mental Health (Care and Treatment) (Scotland) Act 2003 gives patients with capacity the right to refuse ECT.

A study published in 2005 in the "British Journal of Psychiatry" described patients' perspectives of electroshock. The study stated, “About half (45–55%) of patients reported they were given an adequate explanation of ECT, implying a similar percentage felt they were not.” The study also said, “Approximately a third did not feel they had freely consented to ECT even when they had signed a consent form. [deletion] 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. [deletion] Neither current nor proposed safeguards for patients are sufficient to ensure informed consent with respect to ECT, at least in England and Wales.”

Duress in involuntary ECT makes reports about its effects, by patients while under duress, uncertain in their validity. Megara Sanderson, Events & Culture Editor of newspaper "The Flying Horse" reports, "Some speculate that patients may pretend that they are cured of their mental illness so that they no longer have to endure the electro-convulsive treatment."

Involuntary electroshock contravenes the principle of autonomy in medical ethics. The maxim of autonomy is "Voluntas aegroti suprema lex." This rule states that the will of the patient is supreme. It implies that a patient has the right to refuse a medical treatment, such as ECT.

History

As early as the 16th century, agents to produce seizures were used to treat psychiatric conditions. In 1785, the therapeutic use of seizure induction was documented in the London Medical Journa l.]Convulsive therapy was introduced in 1934 by Hungarian neuropsychiatrist Ladislas J. Meduna who, believing mistakenly that schizophrenia and epilepsy were antagonistic disorders, induced seizures with first camphor and then metrazol (cardiazol). Within three years metrazol convulsive therapy was being used worldwide.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. Sherwin B. Nuland, having discussed the matter with a first-hand observer in the 1970's, gave the following description of the results of the first use of ECT on a person:

"They thought, 'Well, we'll try 55 volts, two-tenths of a second. That's not going to do anything terrible to him.' So they did that. [...] This fellow — remember, he wasn't even put to sleep — after this major grand mal convulsion, sat right up, looked at these three fellows and said, 'What the fuck are you assholes trying to do?' Well, they were happy as could be, because he hadn't said a rational word in the weeks of observation."

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. Through the 40's and 50's the use of ECT became widespread. ECT is the only form of shock treatment still performed by modern medicine.

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[ Unilateral ECT has never been popular with psychiatrists and is still only given to a minority of ECT patients.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 50's to the 70's. The Surgeon General stated there were problems with electroshock therapy in the initial years before anesthesia was routinely given and, 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 some ECT clinics in the US still use sine-wave devices.The 1970s saw the publication of the first American Psychiatric Association 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, whilst ECT was the most controversial treatment in psychiatry and had significant side-effects