Electroconvulsive therapy (ECT) is a

psychiatric Psychiatry is the medical specialty devoted to the diagnosis, treatment, and prevention of deleterious mental conditions. These include matters related to cognition, perceptions, mood, emotion, and behavior. Initial psychiatric assessment of ...

treatment that causes a

generalized seizure Generalized epilepsy is a form of epilepsy characterized by generalized seizures that occur with no obvious cause. Generalized seizures, as opposed to focal seizures, are a type of seizure that manifests as impaired consciousness, bilateral motor ...

by passing

electrical current Electricity is the set of physical phenomena associated with the presence and motion of matter possessing an electric charge. Electricity is related to magnetism, both being part of the phenomenon of electromagnetism, as described by Maxwel ...

through the brain. ECT is often used as an intervention for

mental disorder A mental disorder, also referred to as a mental illness, a mental health condition, or a psychiatric disability, is a behavioral or mental pattern that causes significant distress or impairment of personal functioning. A mental disorder is ...

s when other treatments are inadequate. Conditions responsive to ECT include

major depressive disorder Major depressive disorder (MDD), also known as clinical depression, is a mental disorder characterized by at least two weeks of pervasive depression (mood), low mood, low self-esteem, and anhedonia, loss of interest or pleasure in normally ...

mania Mania, also known as manic syndrome, is a Psychiatry, psychiatric Abnormality (behavior), behavioral syndrome defined as a state of Abnormality (behavior), abnormally elevated arousal, affect (psychology), affect, and energy level. During a mani ...

, and

catatonia Catatonia is a complex syndrome most commonly seen in people with underlying mood disorders, such as major depressive disorder, or psychotic disorders, such as schizophrenia. People with catatonia exhibit abnormal movement and behaviors, wh ...

.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, p. 38: "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." The general physical risks of ECT are similar to those of brief

general anesthesia General anaesthesia (UK) or general anesthesia (US) is medically induced loss of consciousness that renders a patient unarousable even by painful stimuli. It is achieved through medications, which can be injected or inhaled, often with an analgesi ...

. Immediately following treatment, the most common adverse effects are confusion and transient memory loss. Among treatments for severely depressed pregnant women, ECT is one of the least harmful to the

fetus A fetus or foetus (; : fetuses, foetuses, rarely feti or foeti) is the unborn offspring of a viviparous animal that develops from an embryo. Following the embryonic development, embryonic stage, the fetal stage of development takes place. Pren ...

. The usual course of ECT involves multiple administrations, typically given two or three times per week until the patient no longer has symptoms. ECT is administered under anesthesia with a

muscle relaxant A muscle relaxant is a drug that affects skeletal muscle function and decreases the muscle tone. It may be used to alleviate symptoms such as muscle spasms, pain, and hyperreflexia. The term "muscle relaxant" is used to refer to two major therapeu ...

. ECT can differ in its application in three ways: electrode placement, treatment frequency, and the electrical waveform of the stimulus. Differences in these parameters affect symptom remission and adverse side effects. Placement can be bilateral, where the electric current is passed from one side of the brain to the other, or unilateral, in which the current is solely passed across one

hemisphere Hemisphere may refer to: In geometry * Hemisphere (geometry), a half of a sphere As half of Earth or any spherical astronomical object * A hemisphere of Earth ** Northern Hemisphere ** Southern Hemisphere ** Eastern Hemisphere ** Western Hemi ...

of the brain. High-dose unilateral ECT has some cognitive advantages compared to moderate-dose bilateral ECT while showing no difference in antidepressant efficacy.

History

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 and Surgical Journal The ''London Medical and Surgical Journal'' was a British medical journal first published as a monthly in 1828. The founding editors-in-chief were John Davies, John Epps, and Joseph Houlton. The editorial line was in favour of medical reform. It a ...

''. 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 Conversion disorder (CD) was a formerly diagnosed psychiatric disorder characterized by abnormal sensory experiences and movement problems during periods of high psychological stress. Individuals diagnosed with CD presented with highly distressin ...

was documented eleven years later.

Benjamin Franklin Benjamin Franklin (April 17, 1790) was an American polymath: a writer, scientist, inventor, statesman, diplomat, printer, publisher and Political philosophy, political philosopher.#britannica, Encyclopædia Britannica, Wood, 2021 Among the m ...

wrote that an electrostatic machine cured "a woman of hysterical fits." By 1801,

James Lind James Lind (4 October 1716 – 13 July 1794) was a Scottish physician. He was a pioneer of naval hygiene in the Royal Navy. By conducting one of the first ever clinical trials, he developed the theory that citrus fruits cured scurvy. Lind ...

as well as

Giovanni Aldini Giovanni Aldini (10 April 1762 – 17 January 1834) was an Italian physician and physicist born in Bologna. He was a brother of the statesman Count Antonio Aldini (1756–1826). He graduated in physics at University of Bologna in 1782. He became ...

had used

galvanism Galvanism is a term invented by the late 18th-century physicist and chemist Alessandro Volta to refer to the generation of electric current by chemical action. The term also came to refer to the discoveries of its namesake, Luigi Galvani, specifi ...

to treat patients with various mental disorders. 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 19th 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 Schizophrenia () is a mental disorder characterized variously by hallucinations (typically, Auditory hallucination#Schizophrenia, hearing voices), delusions, thought disorder, disorganized thinking and behavior, and Reduced affect display, f ...

and

epilepsy Epilepsy is a group of Non-communicable disease, non-communicable Neurological disorder, neurological disorders characterized by a tendency for recurrent, unprovoked Seizure, seizures. A seizure is a sudden burst of abnormal electrical activit ...

were antagonistic disorders, induced seizures first with

camphor Camphor () is a waxy, colorless solid with a strong aroma. It is classified as a terpenoid and a cyclic ketone. It is found in the wood of the camphor laurel (''Cinnamomum camphora''), a large evergreen tree found in East Asia; and in the kapu ...

and then

metrazol Pentylenetetrazol (PTZ), also known as pentylenetetrazole, pentetrazol (International Nonproprietary Name, INN), and pentamethylenetetrazol, is a drug formerly used as a circulatory and respiratory stimulant. High doses cause convulsions, as dis ...

(cardiazol). Meduna is thought to be the father of convulsive therapy. In 1937, the first international meeting on

and

convulsive therapy Electroconvulsive therapy (ECT) is a psychiatric treatment that causes a generalized seizure by passing electrical current through the brain. ECT is often used as an intervention for mental disorders when other treatments are inadequate. Condit ...

was held in Switzerland by the Swiss psychiatrist Max Müller. The proceedings were published in the ''

American Journal of Psychiatry ''The American Journal of Psychiatry'' is a monthly peer-reviewed medical journal covering all aspects of psychiatry, and is the official journal of the American Psychiatric Association. The first volume was issued in 1844, at which time it was k ...

'' and, within three years, cardiazol convulsive therapy was being used worldwide. The ECT procedure was first conducted in 1938 by Italian neuro-psychiatrist

Ugo Cerletti Ugo Cerletti (26 September 1877 – 25 July 1963) was an Italian neurology, neurologist who discovered the method of electroconvulsive therapy (ECT) used in psychiatry. Electroconvulsive therapy is a therapy in which electric current is used to pro ...

and rapidly replaced less safe and effective forms of biological treatments in use at the time. Cerletti, who had been using electric shocks to produce seizures in animal experiments, and his assistant

Lucio Bini Lucio Bini (18 September 1908 – 15 August 1964) was an Italian psychiatrist and professor at the University of Rome La Sapienza, Italy. Together with Ugo Cerletti, a neurophysiologist and a psychiatrist, he researched and discovered the met ...

at Sapienza University of Rome developed the idea of using electricity as a substitute for

in convulsive therapy and, in 1938, experimented for the first time on a person affected by

delusion A delusion is a fixed belief that is not amenable to change in light of conflicting evidence. As a pathology, it is distinct from a belief based on false or incomplete information, confabulation, dogma, illusion, hallucination, or some other m ...

s. It was believed early on that inducing convulsions aided in helping those with severe

but later found to be most useful with

affective disorder Affect, in psychology, is the underlying experience of feeling, emotion, attachment, or mood. It encompasses a wide range of emotional states and can be positive (e.g., happiness, joy, excitement) or negative (e.g., sadness, anger, fear, di ...

s such as depression. 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 In neurology, retrograde amnesia (RA) is the inability to access memories or information from before an injury or disease occurred. RA differs from a similar condition called anterograde amnesia (AA), which is the inability to form new memories f ...

. 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 The Nobel Prizes ( ; ; ) are awards administered by the Nobel Foundation and granted in accordance with the principle of "for the greatest benefit to humankind". The prizes were first awarded in 1901, marking the fifth anniversary of Alfred N ...

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 Friedrich Meggendorfer (June 7, 1880 – February 12, 1953) was a German psychiatrist and neurologist. Life Born in Bad Aibling, Bavaria, he was intended to take over the local colonial goods store of his ancestors. He enjoyed an excellent in ...

. Through the 1940s and 1950s, the use of ECT became widespread. At the time the ECT device was patented and commercialized abroad, the two Italian inventors had competitive tensions that damaged their relationship. In the 1960s, despite a climate of condemnation, the original Cerletti-Bini ECT apparatus prototype was contended by scientific museums between Italy and the US. The ECT apparatus prototype is now owned and displayed by the Sapienza Museum of the History of Medicine in Rome. 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 Alternating current (AC) is an electric current that periodically reverses direction and changes its magnitude continuously with time, in contrast to direct current (DC), which flows only in one direction. Alternating current is the form in w ...

with brief pulse. It took many years for brief-pulse equipment to be widely adopted.Kiloh, LG, Smith, JS, Johnson, GF (1988). ''Physical Treatments in Psychiatry''. Melbourne: Blackwell Scientific Publications, 190–208. In the 1940s and early 1950s, ECT was usually given in an "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 Curare ( or ; or ) is a common name for various alkaloid arrow poisons originating from plant extracts. Used as a paralyzing agent by indigenous peoples in Central and South America for hunting and for therapeutic purposes, curare only ...

, the muscle-paralysing South American poison, in order to modify the convulsions. The introduction of

suxamethonium Suxamethonium chloride (brand names Scoline and Sucostrin, among others), also known as suxamethonium or succinylcholine, or simply sux in medical abbreviation, is a medication used to cause short-term paralysis as part of general anesthesia. T ...

(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 Antidepressants are a class of medications used to treat major depressive disorder, anxiety disorders, chronic pain, and addiction. Common side effects of antidepressants include Xerostomia, dry mouth, weight gain, dizziness, headaches, akathi ...

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 Surgeon general (: surgeons general) is a title used in several Commonwealth countries and most NATO nations to refer either to a senior military medical officer or to a senior uniformed physician commissioned by the government and entrusted with p ...

stated there were problems with electroshock therapy in the initial years before

anesthesia Anesthesia (American English) or anaesthesia (British English) is a state of controlled, temporary loss of sensation or awareness that is induced for medical or veterinary purposes. It may include some or all of analgesia (relief from or prev ...

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 One Flew Over the Cuckoo's Nest may refer to: * ''One Flew Over the Cuckoo's Nest'' (novel), a 1962 novel by Ken Kesey * ''One Flew Over the Cuckoo's Nest'' (play), a 1963 stage adaptation of the novel starring Kirk Douglas * ''One Flew Over the ...

,'' it was a tool of terror, and, in the public mind, ''shock therapy'' has retained the tarnished image given it by

Ken Kesey Ken Elton Kesey (; September 17, 1935 – November 10, 2001) was an American novelist, essayist and Counterculture of the 1960s, countercultural figure. He considered himself a link between the Beat Generation of the 1950s and the hippies o ...

'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 The American Psychiatric Association (APA) is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the largest psychiatric organization in the world. It has more than 39,200 members who are in ...

(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 The National Institute of Mental Health (NIMH) is one of 27 institutes and centers that make up the National Institutes of Health (NIH). The NIH, in turn, is an agency of the United States Department of Health and Human Services and is the primar ...

and

National Institutes of Health The National Institutes of Health (NIH) is the primary agency of the United States government responsible for biomedical and public health research. It was founded in 1887 and is part of the United States Department of Health and Human Service ...

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 Consent occurs when one person voluntarily agrees to the proposal or desires of another. It is a term of common speech, with specific definitions used in such fields as the law, medicine, research, and sexual consent. Consent as understood i ...

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 Informed consent is an applied ethics principle that a person must have sufficient information and understanding before making decisions about accepting risk. Pertinent information may include risks and benefits of treatments, alternative treatme ...

, and the expanded role that the procedure has in modern medicine. By 2017, ECT was routinely covered by insurance companies for providing the "biggest bang for the buck" for otherwise intractable cases of severe

mental illness A mental disorder, also referred to as a mental illness, a mental health condition, or a psychiatric disability, is a behavioral or mental pattern that causes significant distress or impairment of personal functioning. A mental disorder is ...

, was receiving favorable media coverage, and was being provided in regional medical centers. Though ECT use declined with the advent of modern antidepressants, there has been a resurgence of ECT with new modern technologies and techniques. Modern shock voltage is given for a shorter duration of 0.5 milliseconds where conventional brief pulse is 1.5 milliseconds. In a review from 2022 of

neuroimaging Neuroimaging is the use of quantitative (computational) techniques to study the neuroanatomy, structure and function of the central nervous system, developed as an objective way of scientifically studying the healthy human brain in a non-invasive ...

studies based on a global data collaboration, ECT was suggested to work via a temporary disruption of neural circuits followed by augmented

neuroplasticity Neuroplasticity, also known as neural plasticity or just plasticity, is the ability of neural networks in the brain to change through neurogenesis, growth and reorganization. Neuroplasticity refers to the brain's ability to reorganize and rewir ...

and rewiring.

Modern use

ECT is used, where possible, with

in treatment-resistant

bipolar depression Bipolar disorder (BD), previously known as manic depression, is a mental disorder characterized by periods of depression and periods of abnormally elevated mood that each last from days to weeks, and in some cases months. If the elevated m ...

, treatment-resistant

, prolonged or severe

, 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

suicidality Suicide is the act of intentionally causing one's own death. Risk factors for suicide include mental disorders, physical disorders, and substance abuse. Some suicides are impulsive acts driven by stress (such as from financial or acad ...

psychosis In psychopathology, psychosis is a condition in which a person is unable to distinguish, in their experience of life, between what is and is not real. Examples of psychotic symptoms are delusions, hallucinations, and disorganized or inco ...

stupor Stupor is the lack of critical mental function and a level of consciousness, in which an affected person is almost entirely unresponsive and responds only to intense stimuli such as pain. The word derives from the Latin '' stupor'' ("numbness, in ...

, marked

psychomotor retardation Psychomotor retardation involves a slowing down of thought and a reduction of physical movements in an individual. It can cause a visible slowing of physical and emotional reactions, including speech and affect. Psychomotor retardation is most ...

, depressive

s or

hallucination A hallucination is a perception in the absence of an external stimulus that has the compelling sense of reality. They are distinguishable from several related phenomena, such as dreaming ( REM sleep), which does not involve wakefulness; pse ...

s, or life-threatening physical exhaustion associated with mania)." It has also been used to treat

autism Autism, also known as autism spectrum disorder (ASD), is a neurodevelopmental disorder characterized by differences or difficulties in social communication and interaction, a preference for predictability and routine, sensory processing d ...

in adults with an intellectual disability, yet findings from a systematic review found this an unestablished intervention.

Major depressive disorder

For

, despite a Canadian guideline and some experts arguing for using ECT as a first line treatment, ECT is generally used only when one or 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 Multiple sclerosis (MS) is an autoimmune disease resulting in damage to myelinthe insulating covers of nerve cellsin the brain and spinal cord. As a demyelinating disease, MS disrupts the nervous system's ability to Action potential, transmit ...

Parkinson's disease Parkinson's disease (PD), or simply Parkinson's, is a neurodegenerative disease primarily of the central nervous system, affecting both motor system, motor and non-motor systems. Symptoms typically develop gradually and non-motor issues become ...

Huntington's chorea Huntington's disease (HD), also known as Huntington's chorea, is an incurable neurodegenerative disease that is mostly inherited. It typically presents as a triad of progressive psychiatric, cognitive, and motor symptoms. The earliest sympt ...

developmental delay The term developmental delay can refer to: *Global developmental delay, an umbrella term used when children are significantly delayed in two or more areas of development *Specific developmental disorder, a classification of disorders characterize ...

, brain

arteriovenous malformations An arteriovenous malformation (AVM) is an abnormal connection between arteries and veins, bypassing the capillary system. Usually congenital, this vascular anomaly is widely known because of its occurrence in the central nervous system (usually ...

, and

hydrocephalus Hydrocephalus is a condition in which cerebrospinal fluid (CSF) builds up within the brain, which can cause pressure to increase in the skull. Symptoms may vary according to age. Headaches and double vision are common. Elderly adults with n ...

Efficacy

meta-analysis Meta-analysis is a method of synthesis of quantitative data from multiple independent studies addressing a common research question. An important part of this method involves computing a combined effect size across all of the studies. As such, th ...

on the effectiveness of ECT in unipolar and bipolar depression indicated that although patients with

unipolar depression Major depressive disorder (MDD), also known as clinical depression, is a mental disorder characterized by at least two weeks of pervasive depression (mood), low mood, low self-esteem, and anhedonia, loss of interest or pleasure in normally ...

and

responded to other medical treatments very differently, both groups responded equally well to ECT. Overall remission rate for patients given a round of ECT treatment was 50.9% for those with unipolar depression and 53.2% for those with bipolar depression. Most severely depressed patients respond to ECT. In 2004, a meta-analysis found in terms of efficacy, "a significant superiority of ECT in all comparisons: ECT versus simulated ECT, ECT versus

placebo A placebo ( ) can be roughly defined as a sham medical treatment. Common placebos include inert tablets (like sugar pills), inert injections (like saline), sham surgery, and other procedures. Placebos are used in randomized clinical trials ...

, ECT versus antidepressants in general, ECT versus tricyclics and ECT versus

monoamine oxidase inhibitor Monoamine oxidase inhibitors (MAOIs) are a drug class, class of drugs that inhibit the activity of one or both monoamine oxidase enzymes: monoamine oxidase A (MAO-A) and monoamine oxidase B (MAO-B). They are best known as effective antidepressa ...

s." In 2003, the UK ECT Review Group published a

systematic review A systematic review is a scholarly synthesis of the evidence on a clearly presented topic using critical methods to identify, define and assess research on the topic. A systematic review extracts and interprets data from published studies on ...

and meta-analysis comparing ECT to

and antidepressant drugs. This meta-analysis demonstrated a large effect size (high efficacy relative to the mean in terms of the

standard deviation In statistics, the standard deviation is a measure of the amount of variation of the values of a variable about its Expected value, mean. A low standard Deviation (statistics), deviation indicates that the values tend to be close to the mean ( ...

) for ECT versus placebo, and versus antidepressant drugs. Compared with

repetitive transcranial magnetic stimulation Transcranial magnetic stimulation (TMS) is a noninvasive neurostimulation technique in which a changing magnetic field is used to induce an electric current in a targeted area of the brain through electromagnetic induction. A device called a sti ...

(rTMS) for people with treatment-resistant major depressive disorder, ECT relieves depression as shown by reducing the score on the

Hamilton Rating Scale for Depression The Hamilton Rating Scale for Depression (HRSD), also called the Hamilton Depression Rating Scale (HDRS), sometimes also abbreviated as HAM-D, is a multiple-item questionnaire used to provide an indication of Depression (mood), depression, and as ...

by about 15 points, while rTMS reduced it by 9 points. Other estimates regarding the response rate in treatment resistant depression vary between 60–80%, with a remission rate of 50–60%. In addition to reducing symptoms of depression and inducing relapse, ECT has also been shown to reduce the risk of suicide, improve functional outcomes and quality of life as well as reduce the risk of re-hospitalization. Efficacy does not depend on depression subtype. With regards to treatment resistant schizophrenia, the response rate is 40–70%.

Follow-up

There is little agreement on the most appropriate follow-up to ECT for people with major depressive disorder. The initial course of ECT is then transitioned to maintenance ECT, pharmacotherapy or both. When ECT is stopped abruptly, without a bridge to maintenance ECT or medications (usually antidepressants and

Lithium Lithium (from , , ) is a chemical element; it has chemical symbol, symbol Li and atomic number 3. It is a soft, silvery-white alkali metal. Under standard temperature and pressure, standard conditions, it is the least dense metal and the ...

), it is associated with a relapse rate of 84%. There is no defined schedule for maintenance ECT, however it is usually started weekly with intervals extended permissibly with the goal of maintaining remission. When ECT is followed by treatment with

antidepressants Antidepressants are a class of medications used to treat major depressive disorder, anxiety disorders, chronic pain, and addiction. Common side effects of antidepressants include dry mouth, weight gain, dizziness, headaches, akathisia, sexu ...

, about 50% of people relapsed by 12 months following successful initial treatment with ECT, with 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

tricyclic antidepressants Tricyclic antidepressants (TCAs) are a class of medications that are used primarily as antidepressants. TCAs were discovered in the early 1950s and were marketed later in the decade. They are named after their chemical structure, which contains ...

; evidence for relapse prevention with newer antidepressants is lacking. Adjunct maintenance ECT paired with

cognitive behavioral therapy Cognitive behavioral therapy (CBT) is a form of psychotherapy that aims to reduce symptoms of various mental health conditions, primarily depression, PTSD, and anxiety disorders. Cognitive behavioral therapy focuses on challenging and chang ...

has also been shown to reduce relapse rates. Maintenance ECT may safely continue indefinitely, with no set maximum treatment interval established.

has also been found to reduce the risk of relapse, especially in younger patients.

Catatonia

ECT is generally a second-line treatment for people with

who do not respond to other treatments, but is a first-line treatment for severe or life-threatening catatonia. There is a plethora of evidence for its efficacy, notwithstanding a lack of randomised controlled trials, such that "the excellent efficacy of ECT in catatonia is generally acknowledged". For people with

autism spectrum disorders Autism, also known as autism spectrum disorder (ASD), is a neurodevelopmental disorder characterized by differences or difficulties in social communication and interaction, a preference for predictability and routine, sensory processing di ...

who have catatonia, there is little published evidence about the efficacy of ECT.

Mania

ECT is used to treat people who have severe or prolonged

;

NICE Nice ( ; ) is a city in and the prefecture of the Alpes-Maritimes department in France. The Nice agglomeration extends far beyond the administrative city limits, with a population of nearly one millionGuidance on the use of electroconvulsive therapy. NICE technology appraisals TA59
Published date: April 2003 and as a second-line treatment for

bipolar mania Bipolar disorder (BD), previously known as manic depression, is a mental disorder characterized by periods of depression and periods of abnormally elevated mood that each last from days to weeks, and in some cases months. If the elevated m ...

Schizophrenia

ECT is widely used worldwide in the treatment of

. However, in North America and Western Europe it is invariably used only in treatment resistant schizophrenia when symptoms show little response to

antipsychotic Antipsychotics, previously known as neuroleptics and major tranquilizers, are a class of Psychiatric medication, psychotropic medication primarily used to manage psychosis (including delusions, hallucinations, paranoia or disordered thought), p ...

s; there is comprehensive research evidence for such practice. It is useful in the case of severe exacerbations of

catatonic schizophrenia Catatonia is a complex syndrome most commonly seen in people with underlying mood disorders, such as major depressive disorder, or psychotic disorders, such as schizophrenia. People with catatonia exhibit abnormal movement and behaviors, wh ...

, whether excited or stuporous. There are also case reports of ECT improving persistent psychotic symptoms associated with stimulant-induced psychosis.

Effects and adverse effects

Aside from effects on the brain, the general risk for adverse effects stemming from ECT are similar to those of brief

; a

Surgeon General of the United States The surgeon general of the United States is the operational head of the United States Public Health Service Commissioned Corps (PHSCC) and thus the leading spokesperson on matters of public health in the federal government of the United States. T ...

's report stated that there are "no absolute health

contraindications In medicine, a contraindication is a condition (a situation or factor) that serves as a reason not to take a certain medical treatment due to the harm that it would cause the patient. Contraindication is the opposite of indication, which is a rea ...

" to its use. Immediately following treatment, the most common adverse effects are confusion and memory loss. Some patients experience muscle soreness after ECT. Other common adverse effects of ECT include headache, jaw soreness, nausea, vomiting, and fatigue. These side effects are transient and respond to treatment. There is evidence and rationale to support giving low doses of

benzodiazepine Benzodiazepines (BZD, BDZ, BZs), colloquially known as "benzos", are a class of central nervous system (CNS) depressant, depressant drugs whose core chemical structure is the fusion of a benzene ring and a diazepine ring. They are prescribed t ...

s or lower doses of

general anesthetic General anaesthetics (or anesthetics) are often defined as compounds that induce a loss of consciousness in humans or loss of righting reflex in animals. Clinical definitions are also extended to include an induced coma that causes lack of aware ...

s, which induce

sedation Sedation is the reduction of irritability or agitation by administration of sedative drugs, generally to facilitate a medical procedure or diagnostic procedure. Examples of drugs which can be used for sedation include isoflurane, diethyl ether, ...

but not unconsciousness, to patients to reduce the likelihood of adverse effects of ECT. While there are no absolute contraindications for ECT, there is an increased risk for patients who have unstable or severe cardiovascular conditions or

aneurysms An aneurysm is an outward bulging, likened to a bubble or balloon, caused by a localized, abnormal, weak spot on a blood vessel wall. Aneurysms may be a result of a hereditary condition or an acquired disease. Aneurysms can also be a nidus ( ...

; who have recently had a

stroke Stroke is a medical condition in which poor cerebral circulation, blood flow to a part of the brain causes cell death. There are two main types of stroke: brain ischemia, ischemic, due to lack of blood flow, and intracranial hemorrhage, hemor ...

; who have increased

intracranial pressure Intracranial pressure (ICP) is the pressure exerted by fluids such as cerebrospinal fluid (CSF) inside the skull and on the brain tissue. ICP is measured in millimeters of mercury ( mmHg) and at rest, is normally 7–15 mmHg for a supine adu ...

(for instance, due to a solid

brain tumor A brain tumor (sometimes referred to as brain cancer) occurs when a group of cells within the Human brain, brain turn cancerous and grow out of control, creating a mass. There are two main types of tumors: malignant (cancerous) tumors and benign ...

); who have severe pulmonary conditions; or who are generally at high risk for adverse effects from anesthesia. In adolescents, ECT is highly efficient for several psychiatric disorders, with few and relatively benign adverse effects.

Risk of death

A meta-analysis from 2017 found that the death rate of ECT was around 2.1 per 100,000 procedures. A review from 2011 reported an estimated ECT mortality rate of fewer than one death per 73,440 treatments.

Cognitive impairment

Cognitive impairment sometimes occurs after ECT. The

(APA) report in 2001 acknowledged: "In some patients the recovery from

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 non-specific, and their application to people with depressive disorders, who have cognitive deficits related to depression, including problems with memory, may further limit their utility. The acute effects of ECT can include

amnesia Amnesia is a deficit in memory caused by brain damage or brain diseases,Gazzaniga, M., Ivry, R., & Mangun, G. (2009) Cognitive Neuroscience: The biology of the mind. New York: W.W. Norton & Company. but it can also be temporarily caused by t ...

, both

retrograde Retrograde may refer to: Film and television * Retrograde (2004 film), ''Retrograde'' (2004 film), a film by Christopher Kulikowski * Retrograde (2022 American film), ''Retrograde'' (2022 American film), a documentary film by Matthew Heineman * ...

(for events occurring before the treatment) and anterograde (for events occurring after the treatment).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. Memory loss and confusion are more pronounced with bilateral electrode placement rather than unilateral and with outdated sine-wave rather than brief-pulse currents. Using 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 treatments use brief pulse currents. A greater number of treatments and higher electrical charges (stimulus charges) have also been associated with a greater risk of memory impairment. Retrograde amnesia is most marked for events occurring in the weeks or months before treatment. Anterograde memory loss usually resolves 2–4 weeks after treatment, whereas retrograde amnesia (which develops gradually after repeated treatments in the initial course) usually takes weeks to months to resolve; amnesia rarely persists for more than 1 year. Retrograde amnesia after ECT usually affects autobiographical memory rather than

semantic memory Semantic memory refers to general world knowledge that humans have accumulated throughout their lives. This general knowledge (Semantics, word meanings, concepts, facts, and ideas) is intertwined in experience and dependent on culture. New concep ...

. 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 Sarah H. Lisanby (b. ca 1965) is an American psychiatrist who studies the use of neurostimulation devices to treat mental illness. Since 2015 she has directed the division of the National Institute of Mental Health (NIMH) working on translationa ...

and colleagues found that bilateral ECT left patients with more persistently impaired memory of public events as compared to right unilateral ECT. However, bilateral ECT may be more efficacious than unilateral in the treatment of mood disorders. ECT has not been found to increase the risk of dementia or cause structural brain damage.

Effects on brain structure

Considerable controversy exists over the effects of ECT on brain tissue, although a number of mental health associations—including the APA—have concluded that there is no evidence that ECT causes structural brain damage. A 1999 report by the US 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." Kellner cites a study purporting to show an absence of cognitive impairment in eight subjects after more than 100 lifetime ECT treatments. Kellner stated, "Rather than cause brain damage, there is evidence that ECT may reverse some of the damaging effects of serious psychiatric illness." Two meta-analyses find that ECT is associated with brain matter growth.

Effects in pregnancy

If steps are taken to decrease potential risks, ECT is generally considered relatively safe during all trimesters of pregnancy, particularly when compared to pharmacological treatments. Suggested preparation for ECT during pregnancy includes a

pelvic examination A pelvic examination is the physical examination of the external and internal female pelvic organs. It is frequently used in gynecology for the evaluation of symptoms affecting the female reproductive and urinary tract, such as pain, bleeding, ...

, discontinuation of nonessential

anticholinergic Anticholinergics (anticholinergic agents) are substances that block the action of the acetylcholine (ACh) neurotransmitter at synapses in the central nervous system, central and peripheral nervous system. These agents inhibit the parasympatheti ...

medication, uterine tocodynamometry, intravenous hydration, and administration of a nonparticulate

antacid An antacid is a substance which neutralization (chemistry), neutralizes gastric acid, stomach acidity and is used to relieve heartburn, indigestion, or an upset stomach. Some antacids have been used in the treatment of constipation and diarrhe ...

. During ECT, elevation of the pregnant woman's right hip, external fetal cardiac monitoring,

intubation Intubation (sometimes entubation) is a medical procedure involving the insertion of a tube into the body. Most commonly, intubation refers to tracheal intubation, a procedure during which an endotracheal tube is inserted into the trachea to supp ...

, and avoidance of excessive

hyperventilation Hyperventilation is irregular breathing that occurs when the rate or tidal volume of breathing eliminates more carbon dioxide than the body can produce. This leads to hypocapnia, a reduced concentration of carbon dioxide dissolved in the blo ...

are recommended. In many instances of active mood disorder during pregnancy, the risks of untreated symptoms may outweigh the risks of ECT. Modifications in technique can minimize potential complications of ECT during pregnancy. The use of ECT during pregnancy requires a thorough evaluation of the patient's capacity for informed consent.

Effects on the heart

ECT can cause a lack of blood flow and oxygen to the heart,

heart arrhythmia Arrhythmias, also known as cardiac arrhythmias, are irregularities in the cardiac cycle, heartbeat, including when it is too fast or too slow. Essentially, this is anything but normal sinus rhythm. A resting heart rate that is too fast – ab ...

, and "persistent

asystole Asystole (New Latin, from Greek privative a "not, without" + ''systolē'' "contraction") is the absence of ventricular contractions in the context of a lethal heart arrhythmia (in contrast to an induced asystole on a cooled patient on a heart-lun ...

". A 2019

and

of 82 studies found that the rate of major adverse cardiac events with ECT was 1 in 39 patients or about 1 in 200 to 500 procedures. The risk of death with ECT however is low. If death does occur, cardiovascular complications are considered as causal in about 30% of individuals.

Procedure

The placement of electrodes, as well as the dose and duration of the stimulation is determined on a per-patient basis. 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 such as memory loss. In bilateral ECT, the two electrodes are placed on opposite sides of the head. Usually bitemporal placement is used, whereby the electrodes are placed on the temples. Uncommonly bifrontal placement is used; this involves positioning the electrodes on the patient's forehead, roughly above each eye. Unilateral ECT is thought to cause fewer cognitive effects than bilateral treatment, but is less effective unless administered at higher doses. Most patients in the US and almost all in the UKRoyal College of Psychiatrists. Council Report. ''The ECT Handbook: The Third Report of the Royal College of Psychiatrists' Special Committee of ECT.'' RCPsych Publications, 2005 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. 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 Drug titration is the process of adjusting the dose of a medication for the maximum benefit without adverse effects. When a drug has a narrow therapeutic index, titration is especially important, because the range between the dose at which a drug ...

"). 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 Methohexital or methohexitone (marketed under the brand names Brevital and Brietal) is a drug which is a barbiturate derivative. It is classified as short-acting, and has a rapid onset of action. It is similar in its effects to sodium thiopental ...

propofol Propofol is the active component of an intravenous anesthetic formulation used for induction and maintenance of general anesthesia. It is chemically termed 2,6-diisopropylphenol. The formulation was approved under the brand name Diprivan. Nu ...

etomidate Etomidate (United States Adopted Name, USAN, International Nonproprietary Name, INN, British Approved Name, BAN; marketed as Amidate) is a short-acting intravenous anaesthetic agent used for the induction of general anaesthesia and sedation for ...

, or

thiopental Sodium thiopental, also known as Sodium Pentothal (a trademark of Abbott Laboratories), thiopental, thiopentone, or Trapanal (also a trademark), is a rapid-onset short-acting barbiturate general anesthetic. It is the thiobarbiturate analog ...

, a muscle relaxant such as

(succinylcholine), and occasionally

atropine Atropine is a tropane alkaloid and anticholinergic medication used to treat certain types of nerve agent and pesticide poisonings as well as some types of slow heart rate, and to decrease saliva production during surgery. It is typically give ...

to inhibit salivation. Studies have shown that adding ketamine, an NMDA receptor antagonist, to the anesthesia regimen produced greater decreases in depression scores when compared to propofol, methohexital, and thiopental alone. 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. The practice was abolished in Turkey's largest psychiatric hospital in 2008. The patient's

EEG Electroencephalography (EEG) is a method to record an electrogram of the spontaneous electrical activity of the brain. The bio signals detected by EEG have been shown to represent the postsynaptic potentials of pyramidal neurons in the neoc ...

ECG Electrocardiography is the process of producing an electrocardiogram (ECG or EKG), a recording of the heart's electrical activity through repeated cardiac cycles. It is an electrogram of the heart which is a graph of voltage versus time of ...

, and

blood oxygen level Oxygen saturation is the fraction of oxygen-saturated haemoglobin relative to total haemoglobin (unsaturated + saturated) in the blood. The human body requires and regulates a very precise and specific balance of oxygen in the blood. Normal art ...

s are monitored during treatment. ECT is usually administered three times a week, on alternate days, over a course of two to four weeks. Electroconvulsive Therapy

Neuroimaging prior to ECT

Neuroimaging prior to ECT may be useful for detecting intracranial pressure or mass given that patients respond less when one of these conditions exist. Nonetheless, it is not indicated due to high cost and low prevalence of these conditions in patients needing ECT.

Concurrent pharmacotherapy

Whether psychiatric medications are terminated prior to treatment or maintained, varies. However, drugs that are known to cause toxicity in combination with ECT, such as

lithium Lithium (from , , ) is a chemical element; it has chemical symbol, symbol Li and atomic number 3. It is a soft, silvery-white alkali metal. Under standard temperature and pressure, standard conditions, it is the least dense metal and the ...

, are discontinued, and

benzodiazepines Benzodiazepines (BZD, BDZ, BZs), colloquially known as "benzos", are a class of central nervous system (CNS) depressant drugs whose core chemical structure is the fusion of a benzene ring and a diazepine ring. They are prescribed to treat co ...

, which increase the

seizure threshold The term seizure threshold is used to describe the balance between excitatory (glutaminergic) and inhibitory (GABA-ergic) forces in the brain which affect how susceptible a person is to seizures. Those diagnosed with epilepsy or certain other neuro ...

, are either discontinued, a benzodiazepine antagonist is administered at each ECT session, or the ECT treatment is adjusted accordingly. A 2009 RCT provides some evidence indicating that concurrent use of some antidepressant improves ECT efficacy.

Course

ECT is usually done from 6 to 12 times in 2 to 4 weeks but can sometimes exceed 12 rounds. It is also recommended to not do ECT more than 3 times per week. Evidence suggest that ECTs for depression may be stopped if there is no improvement during the first six sessions.

Treatment team

In the US, the medical team performing the procedure typically consists of a psychiatrist, an anesthetist, an ECT treatment nurse or qualified assistant, and one or more recovery nurses. Medical trainees may assist, but only under the direct supervision of credentialed attending physicians and staff.

Devices

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 US 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

watt The watt (symbol: W) is the unit of Power (physics), power or radiant flux in the International System of Units (SI), equal to 1 joule per second or 1 kg⋅m2⋅s−3. It is used to quantification (science), quantify the rate of Work ...

s, and the current flows for between one and six seconds.Lock, T (1995). "Stimulus dosing". In C Freeman (ed.) ''The ECT Handbook''. London: Royal College of Psychiatrists, 72–87. Typically, 70 to 120

volt The volt (symbol: V) is the unit of electric potential, Voltage#Galvani potential vs. electrochemical potential, electric potential difference (voltage), and electromotive force in the International System of Units, International System of Uni ...

s are applied externally to the patient's head, resulting in approximately 800 milliamperes of direct current passing between the electrodes, for a duration of 100

millisecond A millisecond (from '' milli-'' and second; symbol: ms) is a unit of time in the International System of Units equal to one thousandth (0.001 or 10−3 or 1/1000) of a second or 1000 microseconds. A millisecond is to one second, as one second i ...

s to 6 seconds, either from temple to temple (bilateral ECT) or from front to back of one side of the head (unilateral ECT). However, only about 1% of the electrical current crosses the bony skull into the brain because skull impedance is about 100 times higher than skin impedance. In the US, 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.

Mechanism of action

Despite decades of research, the exact mechanism of action of ECT remains elusive. A review from 2022 of

studies based on a global data collaboration, resulted in a model of temporary disruption of neural circuits followed by augmented neuroplasticity and rewiring. Other brain changes observed after ECT include increased

gray matter Grey matter, or gray matter in American English, is a major component of the central nervous system, consisting of neuronal cell bodies, neuropil (dendrites and unmyelinated axons), glial cells (astrocytes and oligodendrocytes), synapses, and ...

volume in the frontolimbic areas including the

hippocampus The hippocampus (: hippocampi; via Latin from Ancient Greek, Greek , 'seahorse'), also hippocampus proper, is a major component of the brain of humans and many other vertebrates. In the human brain the hippocampus, the dentate gyrus, and the ...

and

amygdala The amygdala (; : amygdalae or amygdalas; also '; Latin from Greek language, Greek, , ', 'almond', 'tonsil') is a paired nucleus (neuroanatomy), nuclear complex present in the Cerebral hemisphere, cerebral hemispheres of vertebrates. It is c ...

, increased

white matter White matter refers to areas of the central nervous system that are mainly made up of myelinated axons, also called Nerve tract, tracts. Long thought to be passive tissue, white matter affects learning and brain functions, modulating the distr ...

tracts in the frontal and temporal lobes, increased

monoamine Monoamine neurotransmitters are neurotransmitters and neuromodulators that contain one amino group connected to an aromatic ring by a two-carbon chain (such as -CH2-CH2-). Examples are dopamine, norepinephrine and serotonin. All monoamines are ...

neurotransmitters and increased neurogenesis in the

dentate gyrus The dentate gyrus (DG) is one of the subfields of the hippocampus, in the hippocampal formation. The hippocampal formation is located in the temporal lobe of the brain, and includes the hippocampus (including CA1 to CA4) subfields, and other su ...

. Changes in sleep architecture due to the induced seizures have also been hypothesized as a mechanism of action.

Use

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 and Luxembourg. About 70 percent of ECT patients are women. This may be because 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. In Sweden, which has a complete register of all ECT treatments in the country, in 2013 the rate of persons treated in that year per 100,000 inhabitants was 41. Almost the same rate had already been present in 1975 with 42 patients per 100,000 inhabitants.

United States

ECT became popular in the US in the 1940s. At the time, psychiatric hospitals were overrun with patients whom doctors were desperate to treat and cure. Whereas

lobotomies A lobotomy () or leucotomy is a discredited form of neurosurgical treatment for psychiatric disorder or neurological disorder (e.g. epilepsy, depression) that involves severing connections in the brain's prefrontal cortex. The surgery causes ...

would reduce a patient to a more manageable submissive state, ECT helped to improve mood in those with severe depression. 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 US 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. In the mid-1990s in Texas, 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 United Kingdom, 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 US 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.Fink, M. & Taylor, A.M. (2007
"Electroconvulsive therapy: Evidence and Challenges"
''JAMA'' Vol. 298 No. 3, pp. 330–332.

United Kingdom

In the UK 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 A mood disorder, also known as an affective disorder, is any of a group of conditions of mental and behavioral disorder where the main underlying characteristic is a disturbance in the person's mood. The classification is in the ''Diagnostic ...

; schizophrenia was the next most common diagnosis. Sixteen percent were treated without their consent.Electro convulsive therapy: survey covering the period from January 2002 to March 2002
Department of Health. In 2003, the

National Institute for Health and Care Excellence The National Institute for Health and Care Excellence (NICE) is an executive non-departmental public body of the Department of Health and Social Care (United Kingdom), Department of Health and Social Care. As the national health technolog ...

, a government body which was set up to standardize treatment throughout the

National Health Service The National Health Service (NHS) is the term for the publicly funded health care, publicly funded healthcare systems of the United Kingdom: the National Health Service (England), NHS Scotland, NHS Wales, and Health and Social Care (Northern ...

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".NICE 2003
Electroconvulsive therapy (ECT)
. Retrieved on 2007-12-29. The guidance received a mixed reception. It was welcomed by an editorial in the ''

British Medical Journal ''The BMJ'' is a fortnightly peer-reviewed medical journal, published by BMJ Publishing Group Ltd, which in turn is wholly-owned by the British Medical Association (BMA). ''The BMJ'' has editorial freedom from the BMA. It is one of the world ...

'' but the

Royal College of Psychiatrists The Royal College of Psychiatrists is the main professional organisation of psychiatrists in the United Kingdom, and is responsible for representing psychiatrists, for psychiatric research and for providing public information about mental healt ...

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, and the vast majority of ECT clinics in England, Wales, Northern Ireland and the Republic of Ireland have signed up. The

Mental Health Act 2007 The Mental Health Act 2007 (c 12) is an Act of Parliament, Act of the Parliament of the United Kingdom. It amended the Mental Health Act 1983 and the Mental Capacity Act 2005. It applies to people residing in England and Wales.In Scotland, thes ...

allows people to be treated against their will. This law has extra protections regarding ECT. A patient capable of making the decision can decline the treatment, and in that case treatment cannot be given unless it will save that patient's life or is immediately necessary to prevent deterioration of the patient's condition. A patient may not be capable of making the decision (they "lack capacity"), and in that situation ECT can be given if it is appropriate and also if there are no advance directives that prevent the use of ECT.

China

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. Although the Chinese government stopped classifying

homosexuality Homosexuality is romantic attraction, sexual attraction, or Human sexual activity, sexual behavior between people of the same sex or gender. As a sexual orientation, homosexuality is "an enduring pattern of emotional, romantic, and/or sexu ...

as an illness in 2001, electroconvulsive therapy is still used by some establishments as a form of "

conversion therapy Conversion therapy is the pseudoscientific practice of attempting to change an individual's sexual orientation, romantic orientation, gender identity, or gender expression to align with heterosexual and cisgender norms. Methods that have ...

". Alleged

Internet addiction Internet addiction disorder (IAD), also known as problematic internet use, or pathological internet use, is a problematic compulsive use of the internet, particularly on social media, that impairs an individual's function over a prolonged period ...

(or general unruliness) in

adolescents Adolescence () is a transitional stage of human physical and psychological development that generally occurs during the period from puberty to adulthood (typically corresponding to the age of majority). Adolescence is usually associated with ...

is also known to have been treated with ECT, sometimes without anesthesia, most notably by

Yang Yongxin Yang Yongxin (; born 21 June 1962) is a Chinese psychiatrist who advocated and practiced a highly controversial form of electroconvulsive therapy (ECT) without anesthesia or muscle relaxants as a cure for video game and Internet addiction in ...

. The practice was banned in 2009 after a news story featuring Yang was published.

Society and culture

Controversy

Surveys of public opinion, the testimony of former patients, legal restrictions on the use of ECT 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 January 2011 vote by the 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 with catatonia, major depressive disorder, and bipolar disorder. This may result in the manufacturers of such devices having to do controlled trials on their safety and efficacy for the first time.Duff Wilson for the New York Times. January 28, 201
F.D.A. Panel Is Split on Electroshock Risks
/ref> In justifying their position, panelists referred to the memory loss associated with ECT and the lack of long-term data.

Legal status

Informed consent

The

World Health Organization The World Health Organization (WHO) is a list of specialized agencies of the United Nations, specialized agency of the United Nations which coordinates responses to international public health issues and emergencies. It is headquartered in Gen ...

(2005) advises that ECT should be used only with the informed consent of the patient (or their guardian if their incapacity to consent has been established). 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 any time during a course of ECT. The US 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. According to the US Surgeon General, involuntary treatment is uncommon in the US 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 effectsRose D, Wykes T, Bindman J, Fleischmann P (200
"Information, consent and perceived coercion: patients' perspectives on electroconvulsive therapy"
''

British Journal of Psychiatry The ''British Journal of Psychiatry'' is a peer-reviewed medical journal covering all branches of psychiatry with a particular emphasis on the clinical aspects of each topic. The journal is owned by the Royal College of Psychiatrists and publish ...

'' 186:54–59. and another survey found that about fifty percent of psychiatrists and nurses agreed with them. A 2005 study published in the ''

'' 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:

Involuntary ECT

Procedures for involuntary ECT vary from country to country depending on local

mental health law Mental health law includes a wide variety of legal topics and pertain to people with a diagnosis or possible diagnosis of a mental health condition, and to those involved in managing or treating such people. Laws that relate to mental health incl ...

=United States

= In most states in the US, 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. In 2007, a psychiatric patient in the Creedmoor Psychiatric Center in New York, given the pseudonym of Simone D., won a court ruling which set aside a two-year-old court order to give her electroshock treatment against her will.

=United Kingdom

= Until 2007 in England and Wales, the

Mental Health Act 1983 The Mental Health Act 1983 (c. 20) is an Act of the Parliament of the United Kingdom. It covers the reception, care and treatment of mentally disordered people, the management of their property and other related matters, forming part of the me ...

allowed the use of ECT on detained patients whether or not they had

capacity Capacity or capacities may refer to: Mathematics, science, and engineering * Capacity of a container, closely related to the volume of the container * Capacity of a set, in Euclidean space, the total charge a set can hold while maintaining a giv ...

to consent to it. However, following amendments which took effect in 2007, 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 Advocacy is an Action (philosophy), activity by an individual or advocacy group, group that aims to influence decision making, decisions within political, economic, and social institutions. Advocacy includes activities and publications to infl ...

. In Scotland, the Mental Health (Care and Treatment) (Scotland) Act 2003 also gives patients with capacity the right to refuse ECT.

Regulation

In the US, ECT devices came into existence prior to medical devices being regulated by the

Food and Drug Administration The United States Food and Drug Administration (FDA or US FDA) is a List of United States federal agencies, federal agency of the United States Department of Health and Human Services, Department of Health and Human Services. The FDA is respo ...

. In 1976, the

Medical Device Regulation Act The Medical Device Regulation Act or Medical Device Amendments of 1976 was introduced by the 94th Congress of the United States. Congressman Paul G. Rogers and Senator Edward M. Kennedy were the chairperson sponsors of the medical device amendm ...

required the FDA to retrospectively review already existing devices, classify them, and determine whether clinical trials were needed to prove efficacy and safety. The FDA initially classified the devices used to administer ECT as Class III medical devices. In 2014, the

petitioned the FDA to reclassify ECT devices from Class III (high-risk) to Class II (medium-risk). A similar reclassification proposal in 2010 did not pass. In 2018, the FDA re-classified ECT devices as Class II devices when used to treat catatonia or a severe major depressive episode associated with major depressive disorder or bipolar disorder.

By country

= Australia

= In

Western Australia Western Australia (WA) is the westernmost state of Australia. It is bounded by the Indian Ocean to the north and west, the Southern Ocean to the south, the Northern Territory to the north-east, and South Australia to the south-east. Western Aust ...

, ECT has been heavily restricted since 2014, after a bill passed with bipartisan support introducing restrictions on ECT, which were welcomed by mental health experts. Children under 14 are prohibited from receiving ECT, while those aged 14 to 18 must have informed consent approval from the Mental Health Tribunal. The law imposes a $15,000 fine on anyone who performs ECT on a child under the age of 14. Similarly, ECT is also banned on children under the age of 12 in the

Australian Capital Territory The Australian Capital Territory (ACT), known as the Federal Capital Territory until 1938, is an internal States and territories of Australia, territory of Australia. Canberra, the capital city of Australia, is situated within the territory, an ...

(ACT).

= United States

= Many mental health facilities offer ECT for specific diagnoses, such as

chronic depression Dysthymia ( ), known as persistent depressive disorder (PDD) in the DSM-5-TR and dysthymic disorder in ICD-11, is a psychiatric condition marked by symptoms that are similar to those of major depressive disorder, but which persist for at least ...

and

. However, ECT is often only used as a treatment of last resort. To be considered for ECT, often testing such as an EKG and lab tests are required, in addition to a physical and neurological exam. Certain medications and conditions, such as cardiac conditions or hypertension, may disqualify a patient from ECT. Patients should give proper informed consent before ECT is performed. In the United States, ECT is performed under general anesthesia. Both trained health professionals with experience in ECT administration as well as a specifically trained and certified anesthesiologist should administer the procedure and anesthesia respectively.

Public perception

A questionnaire survey of 379 members of the general public in

Australia Australia, officially the Commonwealth of Australia, is a country comprising mainland Australia, the mainland of the Australia (continent), Australian continent, the island of Tasmania and list of islands of Australia, numerous smaller isl ...

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. A sample of the general public,

medical students A medical school is a tertiary educational institution, professional school, or forms a part of such an institution, that teaches medicine, and awards a professional degree for physicians. Such medical degrees include the Bachelor of Medicine, ...

, and

psychiatry Psychiatry is the medical specialty devoted to the diagnosis, treatment, and prevention of deleterious mental disorder, mental conditions. These include matters related to cognition, perceptions, Mood (psychology), mood, emotion, and behavior. ...

trainees in the

United Kingdom The United Kingdom of Great Britain and Northern Ireland, commonly known as the United Kingdom (UK) or Britain, is a country in Northwestern Europe, off the coast of European mainland, the continental mainland. It comprises England, Scotlan ...

found that the psychiatry trainees were more knowledgeable and had more favorable opinions of ECT than did the other groups. More members of the general public believed that ECT was used for control or punishment purposes than medical students or psychiatry trainees.

Famous cases

Ernest Hemingway Ernest Miller Hemingway ( ; July 21, 1899 – July 2, 1961) was an American novelist, short-story writer and journalist. Known for an economical, understated style that influenced later 20th-century writers, he has been romanticized fo ...

, an American author, died by suicide in 1961 half a year after ECT treatment at the

Mayo Clinic Mayo Clinic () is a Nonprofit organization, private American Academic health science centre, academic Medical centers in the United States, medical center focused on integrated health care, healthcare, Mayo Clinic College of Medicine and Science ...

in 1960. 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." However, the same biographer ( Hotchner, 1966) and also a second biographer ( Lynn, 1987) emphasized - according to a review from 2008 - "that Hemingway’s serious mental illness and plans for suicide significantly predated his ECT treatments." * Robert Pirsig had a nervous breakdown and spent time in and out of psychiatric hospitals between 1961 and 1963. He was diagnosed with paranoid schizophrenia and clinical depression as a result of an evaluation conducted by psychoanalysts, and was treated with electroconvulsive therapy on numerous occasions, a treatment he discusses in his novel, ''

Zen and the Art of Motorcycle Maintenance ''Zen and the Art of Motorcycle Maintenance: An Inquiry into Values'' is a book by Robert M. Pirsig first published in 1974. It is a work of fictionalized autobiography and the first of Pirsig's texts in which he discusses his concept of Quali ...

''. *

Thomas Eagleton Thomas Francis Eagleton (September 4, 1929 – March 4, 2007) was an American lawyer who served as a United States senator from Missouri from 1968 to 1987. He was briefly the Democratic vice presidential nominee under George McGovern in 1972. H ...

United States Senator The United States Senate consists of 100 members, two from each of the 50 U.S. state, states. This list includes all senators serving in the 119th United States Congress. Party affiliation Independent Senators Angus King of Maine and Berni ...

from

Missouri Missouri (''see #Etymology and pronunciation, pronunciation'') is a U.S. state, state in the Midwestern United States, Midwestern region of the United States. Ranking List of U.S. states and territories by area, 21st in land area, it border ...

, was dropped from the Democratic ticket in the

1972 United States Presidential Election Presidential elections were held in the United States on November 7, 1972. Incumbent Republican President Richard Nixon and Vice President Spiro Agnew defeated Democratic Senator George McGovern and former Ambassador Sargent Shriver in ...

as the party's vice presidential candidate after it was revealed that he had received electroshock treatment in the past for depression. Presidential nominee

George McGovern George Stanley McGovern (July 19, 1922 – October 21, 2012) was an American politician, diplomat, and historian who was a U.S. representative and three-term U.S. senator from South Dakota, and the Democratic Party (United States), Democ ...

replaced him with

Sargent Shriver Robert Sargent Shriver Jr. (November 9, 1915 – January 18, 2011) was an American diplomat, politician, and activist. He was a member of the Shriver family by birth, and a member of the Kennedy family through his marriage to Eunice Kennedy. ...

, and later went on to lose by a landslide to

Richard Nixon Richard Milhous Nixon (January 9, 1913April 22, 1994) was the 37th president of the United States, serving from 1969 until Resignation of Richard Nixon, his resignation in 1974. A member of the Republican Party (United States), Republican ...

. * American surgeon and award-winning author

Sherwin B. Nuland Sherwin Bernard Nuland (born Shepsel Ber Nudelman; December 8, 1930 – March 3, 2014) was an American surgeon and writer who taught bioethics, history of medicine, and medicine at the Yale School of Medicine, and occasionally bioethics and hist ...

is another notable person who has undergone ECT. In his 40s, his 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 was successful. * Author

David Foster Wallace David Foster Wallace (February 21, 1962 – September 12, 2008) was an American writer and professor who published novels, short stories, and essays. He is best known for his 1996 novel ''Infinite Jest'', which ''Time (magazine), Time'' magazine ...

also received ECT for many years, beginning as a teenager, before his suicide at age 46. * New Zealand author

Janet Frame Janet Paterson Frame (28 August 1924 – 29 January 2004) was a New Zealand author. She is internationally renowned for her work, which includes novels, short stories, poetry, juvenile fiction, and an autobiography, and received numerous award ...

experienced both insulin coma therapy and ECT (but without the use of anesthesia or muscle relaxants). She wrote about this in her autobiography, ''

An Angel at My Table ''An Angel at My Table'' is a 1990 biographical drama film directed by Jane Campion. The film is based on Janet Frame's three autobiographies, ''To the Is-Land'' (1982), ''An Angel at My Table'' (1984), and ''The Envoy from Mirror City'' (1984) ...

'' (1984), which was later adapted into a film (1990). * American actor

Carrie Fisher Carrie Frances Fisher (October 21, 1956 – December 27, 2016) was an American actress and writer. She played Princess Leia in the Star Wars original trilogy, original ''Star Wars'' films (1977–1983) and reprised the role in'' Star Wars: The F ...

wrote about her experience with memory loss after ECT treatments in her memoir '' Wishful Drinking.'' *

Lou Reed Lewis Allan Reed (March 2, 1942October 27, 2013) was an American musician and songwriter. He was the guitarist, singer, and principal songwriter for the rock band the Velvet Underground and had a solo career that spanned five decades. Althoug ...

had ECT as a teenager to "cure" his homosexuality. He later claimed it had induced multiple personality disorder, and resulted in his hatred of psychiatrists. After Reed's death, his sister denied the ECT treatments were intended to suppress his "homosexual urges", asserting that their parents were not

homophobic Homophobia encompasses a range of negative attitudes and feelings toward homosexuality or people who identify or are perceived as being lesbian, Gay men, gay or bisexual. It has been defined as contempt, prejudice, aversion, hatred, or ant ...

but had been told by his doctors that ECT was necessary to treat Reed's mental and behavioral issues. * On October 31, 2024, a Chinese transgender woman was approved by Changli county people’s court in

Qinhuangdao Qinhuangdao (; zh, s=秦皇岛, link=no) is a port city on the coast of China in northern Hebei. It is administratively a prefecture-level city, about east of Beijing, on the Bohai Sea, the innermost gulf of the Yellow Sea. Its population d ...

to receive 60,000 yuan (£6,552) in compensation from a hospital that gave her electroshock conversion treatment against her will. This was the first time any transgender person in China won a legal challenge against the use of electroshock conversion treatment.

Fictional examples

Electroconvulsive therapy has been depicted in fiction, including fictional works partly based on true experiences. These include

Sylvia Plath Sylvia Plath (; October 27, 1932 – February 11, 1963) was an American poet and author. She is credited with advancing the genre of confessional poetry and is best known for '' The Colossus and Other Poems'' (1960), '' Ariel'' (1965), a ...

's semi-autobiographical novel, ''

The Bell Jar ''The Bell Jar'' is the only novel written by the American writer and poet Sylvia Plath. Originally published under the pseudonym "Victoria Lucas" in 1963, the novel is supposedly semi-autobiographical with the names of places and people change ...

'',

Ken Loach Kenneth Charles Loach (born 17 June 1936) is a retiredhttps://variety.com/2024/film/global/ken-loach-retirement-the-old-oak-jonathan-glazer-oscars-speech-1235956589/ English filmmaker. His socially critical directing style and socialist views ar ...

's film ''Family Life'', and

's novel ''

''; Kesey's novel is a direct product of his time working the

graveyard shift The shift plan, rota or roster (esp. British) is the central component of a shift schedule in shift work. The schedule includes considerations of shift overlap, shift change times and alignment with the clock, vacation, training, shift differenti ...

as an orderly at a mental health facility in Menlo Park, California. Two analyses of large numbers of films using ECT scenes found that almost all presented fictional settings that were unrelated to real treatment routines and were apparently aimed at stigmatizing ECT as a tool of repression and of mind and behavior control - having effects of memory-erosion, pain and damage. The song “The Mind Electric” by Miracle Musical is typically interpreted as depicting someone undergoing ECT. In the television series "

Mr Bates vs The Post Office ''Mr Bates vs The Post Office'' is a four-part British television drama series for ITV, written by Gwyneth Hughes, directed by James Strong and starring an ensemble cast led by Toby Jones. The series is a dramatisation of the British Post Of ...

", which is based on true events, the character of Saman Kaur receives ECT following a deep depression and attempted

suicide Suicide is the act of intentionally causing one's own death. Risk factors for suicide include mental disorders, physical disorders, and substance abuse. Some suicides are impulsive acts driven by stress (such as from financial or ac ...

References

External links

Position Statement on Electroconvulsive Therapy (ECT) 2015
nbsp;– from the

.
ECT
– information from mental health charity The Royal College of Psychiatrists {{DEFAULTSORT:Electroconvulsive Therapy Human subject research in psychiatry Psychiatry controversies Neurotechnology Physical psychiatric treatments Treatment of bipolar disorder Treatment of depression

History

Modern use

Major depressive disorder

Efficacy

Follow-up

Catatonia

Mania

Schizophrenia

Effects and adverse effects

Risk of death

Cognitive impairment

Effects on brain structure

Effects in pregnancy

Effects on the heart

Procedure

Neuroimaging prior to ECT

Concurrent pharmacotherapy

Course

Treatment team

Devices

Mechanism of action

Use

United States

United Kingdom

China

Society and culture

Controversy

Legal status

Informed consent

Involuntary ECT

=United States

=United Kingdom

Regulation

By country

= Australia

= United States

Public perception

Famous cases

Fictional examples

See also

References

External links