New published evidence considered in this surveillance review

Our search identified 32 studies relevant to NICE guidance TA59 and 22 for NICE guideline NG222. Studies with fewer than 60 participants were excluded as such small sample size is unlikely to have a substantial impact on recommendations.

Evidence on ECT across conditions in NICE guidance TA59

The 32 studies assessed ECT's efficacy, cognitive side effects, and long-term effectiveness across various conditions. The evidence is summarised below by condition, including schizophrenia, mania, bipolar disorder, psychotic depression and catatonia.

Schizophrenia

Studies on ECT in people with schizophrenia present mixed findings on its effectiveness, long-term benefits, and associated risks.

The Cochrane review by Sinclair et al. (2019) (15 RCTs, n=1,285) assessed the efficacy and safety of ECT for treatment-resistant schizophrenia (TRS). The review found that adding ECT to standard care improved clinical response in the medium term. However, the superiority of ECT over sham ECT or antipsychotics remained unclear. Evidence on cognitive side effects, particularly memory deterioration, raised safety concerns of the procedure, highlighting the need for higher-quality evidence to establish its benefits and harms. Similarly, Zheng et al. (2016) (11 RCTs, n=818) confirmed that adjunctive ECT improved symptoms compared to antipsychotics alone, but cognitive impairments, such as memory loss, were common in the ECT group, suggesting that while ECT effectively manages symptoms, its cognitive side effects remain a concern.

In the context of clozapine-resistant schizophrenia (CRS), Yeh et al. (2022) (35 RCTs, n=1,472) conducted a systematic review and network meta-analysis, ranking ECT as one of the most effective treatments for improving positive symptoms and overall symptom reduction, although they emphasised the need for further large-scale RCTs to assess cognitive function and quality of life. Similarly, Porcelli et al. (2021) (62 studies, n=1,556) reviewed augmentation strategies for CRS and found that ECT showed promise but noted the need for more consistent evidence.

Wang et al. (2018) in their systematic review of 18 RCTs (n=1,769) on clozapine augmentation in CRS, suggested that adjunctive ECT significantly improved symptoms compared to clozapine alone. However memory impairment and headaches were more common with ECT, but no significant differences in other adverse effects or discontinuation rates were observed. Zheng et al. (2017) reviewed 11 RCTs (n=1,018) on memory impairment from ECT combined with antipsychotics in people with schizophrenia. The study found greater memory impairment during the ECT course, but no lasting effects were seen after 1-2 weeks.

Broader applications and population-specific findings

Broader studies have also examined ECT's effectiveness in different patient populations. Rosson et al. (2022) conducted an umbrella review of 102 meta-analyses on non-pharmacological biological interventions, including ECT. Their findings suggested moderate evidence supporting ECT's effectiveness for schizophrenia, however, the overall quality of the studies was mixed, and they called for further high-quality research. Kumagaya and Halliday (2019) examined in a systematic review the effects of acute ECT in elderly patients with schizophrenia and people with schizoaffective disorder. Their review found that ECT improved psychotic symptoms in nearly all cases, including those with treatment-resistant conditions. Importantly, no fatalities or severe medical complications were reported, suggesting that ECT can be a viable option for this demographic.

Maintenance ECT and long-term efficacy

The long-term efficacy of ECT remains uncertain, with several studies highlighting relapse and maintenance strategies. Aoki et al. (2024) carried out a systematic review of post-acute ECT relapse and re-hospitalisation for schizophrenia and related disorders (29 studies including 4 RCTs, n=3,876) and found that relapse rates were high within the first 6 months post-treatment. However, combining maintenance ECT with antipsychotics appeared to reduce these rates, underscoring the need for long-term treatment strategies. Ward et al. (2018) reviewed studies (including RCTs, open-label trials, retrospective chart reviews, case reports, and case series) on maintenance ECT (M-ECT) in people with schizophrenia and found it to be effective in preventing relapse with minimal persistent cognitive side effects. Mishra et al. (2022) carried out an RCT with 60 treatment-resistant schizophrenia patients, comparing maintenance M-ECT to clozapine. M-ECT showed significantly greater reductions in symptoms, and illness severity, and improved global functioning over 24 weeks. Maintenance ECT also led to better cerebral perfusion in prefrontal and temporal cortices, suggesting superior efficacy over clozapine.

Mania, bipolar disorder psychotic depression

Mania

Loo et al. (2011) reviewed studies on ECT and other brain stimulation techniques for bipolar disorder, concluding that ECT is highly effective in managing both mania and treatment-resistant cases. However, they noted that limited evidence exists on the use of ECT for mixed affective states, where both mania and depression occur simultaneously. Supporting this, Zhang et al. (2021), in their meta-analysis of 12 RCTs (n=863), found that ECT combined with medication (ECT-combo) was effective for treating acute mania. They also noted memory impairment as a common side effect of the treatment.

Versiani et al. (2011) conducted a systematic review of 51 studies on the effectiveness of ECT in treating acute mania in bipolar disorder (only 3 RCTs assessed ECT for mania). The review confirmed that ECT is highly effective for managing acute manic episodes, particularly when pharmacological treatments fail. However, the role of ECT in treating bipolar disorder was found to be less clear, underscoring the need for further research in this area.

Additionally, Perez Garcia et al. (2022) performed a systematic review of 28 studies (including n=19 RCTs), focusing on the treatment of mania with mixed features in bipolar disorder. Their findings emphasised that second-generation antipsychotics are considered the first-line treatment, with ECT serving as a secondary option for treatment-resistant cases. While ECT was shown to be effective for acute manic episodes, the study highlighted the need for further exploration regarding its role in managing mixed features of the disorder.

Bipolar disorder

Elsayed et al. (2022), in their systematic review of RCTs on therapeutic trends and challenges in treatment-resistant bipolar disorder, found that ECT was effective in improving symptoms, particularly in pharmacotherapy resistant patients. However, full remission was not achieved in most cases. Similarly, Fornaro et al. (2020), in a systematic review and meta-analysis of 17 RCTs (n=928), found that ECT was as effective for treatment-resistant bipolar disorder as it is for treatment-resistant unipolar depression. While ECT led to significant symptom improvement, it did not result in full remission.

Further studies explored the cognitive effects of ECT in bipolar disorder. Bjoerke-Bertheussen et al. (2018) conducted an RCT (n=73) to investigate the long-term neurocognitive effects of right unilateral ECT (RUL-ECT) compared to pharmacological treatment for bipolar depression. Their findings showed no greater cognitive impairment with ECT, although autobiographical memory was mildly affected. Similarly, Kessler et al. (2014)) and Schoeyen et al. (2015) (RCT, n=73) examined the neurocognitive and therapeutic effects of RUL-ECT in treatment-resistant bipolar depression. Studies reported that RUL-ECT improved cognitive function and reduced depressive symptoms more effectively than pharmacological treatment, with a slight reduction in autobiographical memory consistency in the ECT group. Schoeyen et al. (2015) also noted that ECT had a significantly higher response rate (73.9%) compared to pharmacological treatments (35%), underlining its importance for patients with treatment-resistant depression.

Additionally, Wilkinson et al. (2022) conducted a systematic review of 57 studies to evaluate the effectiveness of lithium in reducing suicide risk in bipolar disorder. While the review did not focus directly on ECT for suicide prevention, it noted that ECT is effective in managing acute mood episodes, especially when pharmacological treatments fail. Takamiya et al. (2022), in their systematic review of 41 studies (n=1,299), they examined the effectiveness of ECT for severe episodes of bipolar disorder in patients who lacked decision-making capacity. The study found that ECT was effective in treating acute episodes, with a favorable safety profile.,.

Psychotic depression

Al-Wandi et al. (2022) reviewed 5 RCTs on maintenance ECT for people with psychotic depression, including a comparison of antidepressant plus ECT versus antidepressant monotherapy. The analysis found no significant difference between the two treatments, emphasising the need for further research to better understand the role of ECT in maintenance therapy for people with psychotic depression. Similarly, Smith et al. (2010) carried out an RCT (n=85) comparing memory effects of continuation ECT and pharmacotherapy in people with psychotic depression. The study found no significant differences in memory outcomes between the two treatments.

Catatonia

Catatonia, often observed in severe psychotic conditions, has also been a focus of ECT research. Leroy et al. (2018) reviewed 28 studies (n=564) on the efficacy of ECT for catatonia. The findings indicated that ECT is effective in improving catatonic symptoms, but the authors highlighted the need for higher-quality RCTs to establish standardised treatment protocols. Pelzer et al. (2018) reviewed 31 studies (RCTs and observational studies) on catatonia treatment and found lorazepam and ECT to be effective, with ECT showing a more consistent response. However, the authors concluded that the evidence was insufficient to establish a standardised treatment protocol, highlighting the need for more rigorous studies.

ECT in pregnant women and older adults

Arnison et al. (2023), analysing Swedish nationwide registry data on 97 pregnancies where women received ECT for severe psychiatric disorders, found that the response rate was similar to non-pregnant women, with no direct complications linked to ECT. However, there was a higher risk of premature birth and lower Apgar scores, highlighting the need for careful monitoring during treatment. Similarly, Leiknes et al. (2014), in their systematic review (n=169) on ECT during pregnancy, it reported that ECT was primarily used during the second trimester for depression or bipolar disorder. While ECT was generally safe, there were adverse effects such as foetal heart rate reduction, uterine contractions, and premature labour in about 29% of cases. They indicated that these findings underline the need for ECT to be considered a last-resort treatment during pregnancy.

Rose et al. (2020) reviewed 4 meta-analyses on ECT safety during pregnancy, concluding that it is both effective and safe when managed by a multidisciplinary team. Despite underuse due to stigma and access barriers, they noted that serious adverse outcomes from ECT are rare. Special consideration should, however, be given to risks like aspiration and foetal heart rate changes.

In older adults, Lisanby et al. (2021) examined the neurocognitive effects of right unilateral ultra-brief pulse ECT (RUL-UB ECT) combined with pharmacotherapy in patients aged 60 and older with major depression in an RCT. Over 6 months, they found similar neurocognitive outcomes for both ECT plus pharmacotherapy and pharmacotherapy alone, with improvements in most cognitive areas except processing speed. This suggests that RUL-UB ECT can safely maintain remission in late-life depression.

Hedna et al. (2024) conducted a Swedish register-based study comparing suicidal behaviour and all-cause mortality in adults aged 75+ who received ECT (n=1,802) versus other depression treatments (n=4,457). The study found no increased risk of suicidal behaviour in the ECT group and observed lower all-cause mortality among ECT recipients. While this suggests a potential survival benefit, the authors caution against assuming causality due to possible confounding factors.

Lastly, Su et al. (2023), in a secondary analysis of an RCT (n=239), identified predictors of ECT outcomes in major depressive disorder (MDD). The study found that patients with severe depression at baseline had a quicker response to ECT, while older patients and those with severe symptoms showed a slower response. These findings offer valuable insights for guiding treatment decisions in MDD patients undergoing ECT.

Impact on NICE guidance TA59 recommendations

NICE guidance TA59 currently recommends against the general use of ECT in schizophrenia due to insufficient evidence supporting its widespread use (recommendation 1.9). However, emerging research suggests ECT may be beneficial in specific cases, particularly treatment-resistant schizophrenia (TRS) and clozapine-resistant schizophrenia (CRS). Systematic reviews and meta-analyses, including Sinclair et al. (2019) and Zheng et al. (2016), indicate that adjunctive ECT improves symptoms in TRS, though cognitive side effects remain a concern. In CRS, Yeh et al. (2022) and Porcelli et al. (2021) highlight ECT's effectiveness in symptom reduction but call for more consistent evidence. Wang et al. (2018) further support symptom improvement with ECT in CRS despite some cognitive side effects, while Zheng et al. (2017) suggest memory impairment is temporary. Broader studies, including Rosson et al. (2022), provide moderate evidence for supporting ECT's role in schizophrenia, and Kumagaya and Halliday (2019) report benefits in elderly patients without severe complications.

Based on new evidence, we propose updating the recommendations on the use of ECT in people with schizophrenia in NICE guidance TA59, particularly people with TRS and CRS. Given the move of the recommendations on the use of ECT in depression from TA59 to the guideline we propose that in this population should be in CG178 rather than TA59.

Maintenance ECT: The evidence supports the recommendation that repeat and maintenance ECT could be considered primarily for individuals who previously responded well, particularly in cases of catatonia and mania (recommendation 1.7). Studies on maintenance ECT (Aoki et al., 2024; Ward et al., 2018) suggest that it can help prevent relapse, especially when combined with medication. However, the long-term benefits remain uncertain, reinforcing the guidance's emphasis on careful assessment before proceeding with repeat ECT.
Bipolar disorder and psychotic Depression: Findings reinforce TA59's selective use of ECT for severe cases. While ECT is shown to be effective in severe bipolar disorder and psychotic depression, the evidence is mixed regarding its long-term benefits and cognitive effects (Fornaro et al., 2020; Al-Wandi et al., 2022). This aligns with current recommendations on cautious use, as the studies do not support broadening its use beyond severe and life-threatening cases. Therefore, the new evidence reinforces rather than challenges TA59's recommendations, confirming that ECT should remain a selective treatment reserved for urgent and treatment-resistant conditions.
Catatonia and mania: Studies confirm ECT's effectiveness for rapid symptom relief in severe cases. The reviewed evidence supports TA59 recommendation 1.1 that ECT should be used for rapid and short-term symptom relief in severe and treatment-resistant cases of mania and catatonia. Studies consistently demonstrate ECT's effectiveness in acute mania, particularly when pharmacological treatments fail (Loo et al., 2011; Versiani et al., 2011; Zhang et al., 2021), reinforcing its role as the last option in treatment-resistant cases. Similarly, for catatonia, the evidence (Leroy et al., 2018; Pelzer et al., 2018) confirms ECT's efficacy, indicating that further rigorous studies are needed.
Pregnant people & Older Adults: The findings support the recommendation that clinicians should exercise caution when considering ECT in pregnant women, older adults, and young people (recommendation 1.3). While studies (Arnison et al., 2023; Rose et al., 2020) suggest that ECT can be safe and effective during pregnancy, risks such as preterm labour and fetal distress require careful clinical supervision. Similarly, research on older adults (Lisanby et al., 2021; Su et al., 2023) indicates that while ECT can be well-tolerated, response rates may be slower, which requires personalised treatment planning.

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2025 surveillance of electroconvulsive therapy (technology appraisal guidanceTA59, NICE guideline NG222, NICE guideline CG178, NICE guideline CG185, NICE guideline CG192)