Editorial: Electroconvulsive therapy: from mechanisms to clinical practice

Cristiana Tapoi^1*Laith Alexander²Mariana Pinto da Costa²Joao Luciano De Quevedo³Mario F. Juruena²

• ¹Prof. Dr. Alexandru Obregia Psychiatry Hospital, Bucharest, Romania
• ²King's College London Institute of Psychiatry Psychology & Neuroscience, London, United Kingdom
• ³The University of Texas Health Science Center at Houston John P and Katherine G McGovern Medical School, Houston, United States

Electroconvulsive therapy (ECT) continues to be a mainstay in clinical practice due to its proven effectiveness (Liu et al., 2024;Rosson et al., 2022;Mukhtar et al., 2023), despite a longstanding history of stigma and controversy (McDonald et al., 2009;Wilhelmy et al., 2020;Brender et al., 2018). In recent years, alongside advancements in technology, clinical attitudes toward ECT have improved significantly (Dominiak et al., 2021;Wilhelmy et al., 2018;Sackheim et al., 2017;Vera et al., 2016). A cross-sectional survey conducted in Europe reported that early-career psychiatrists generally expressed favorable views toward ECT and a strong interest in expanding their knowledge of the procedure. Access to ECT training during psychiatry residency was associated with a greater likelihood of endorsing its safety and effectiveness, thus reinforcing the importance of continuing education and research in this area (Țăpoi et al., 2025). This research topic brings together 11 articles covering a wide range of topics relevant to modern ECT practice, integrating insights into its mechanisms of action, clinical optimization, and the perspectives of patients, caregivers and clinicians. By combining recent advances in neurobiological and neuroimmune research with ongoing efforts to improve clinical practice, this collection highlights the dynamic bench-to-bedside trajectory of modern ECT practice.João et al. conducted a comprehensive review of 26 studies investigating potential biomarkers related to the immune-inflammatory, structural and cellular mechanisms underlying ECT's therapeutic effects. Their findings provide valuable evidence for reductions in inflammatory markers, increased hippocampal neurogenesis, enhanced BDNF expression, and long-term cellular reprogramming following treatment, helping to close the gap in our understanding of ECT's efficacy.Ruiz et al. presented a narrative review focusing on ECT in treatment-resistant depression (TRD). Their analysis highlights ECT's superior efficacy in severe depression episodes, particularly life-threatening conditions where rapid symptom relief is essential, compared with other interventions known to have efficacy in TRD, such as ketamine or transcranial magnetic stimulation. The review also sheds light on the ECT's impact on neurotransmitter systems, neurogenesis, brain networks and the immune system, which serve as potential pathways in which ECT exerts its antidepressant effect. The authors emphasise the need for larger, longitudinal, and standardised studies to help us understand the predictors of ECT's response and its underlying mechanisms.Zhang et al. performed a retrospective analysis of medical records from 895 patients who underwent ECT during 10 months, investigating the incidence and risk factors for a fever episode within 24 hours post-treatment. They found that 11.6% of patients developed fever within 24 hours post-treatment, with risk factors including male sex, younger age, being treated in a closed psychiatric ward, and receiving etomidate. These results underline the importance of vigilant temperature monitoring after ECT, especially in high-risk groups.Zhiping et al. conducted a retrospective study on the efficacy of ECT in patients diagnosed with schizophrenia, together with factors predicting response. Their study included 237 inpatients in China who received ECT between January 2023 and December 2024. Their results revealed an overall ECT response rate of 70.46%. Positive predictors of treatment response included first-episode schizophrenia, higher baseline positive symptom scores, and longer EEG seizure duration, while older age and more prolonged illness duration were negative predictors. These findings emphasise ECT's value in early psychosis treatment and the need for personalised ECT treatment protocols.Bobo et al. conducted a scoping review of 82 studies evaluating ECT in perinatal depression, including its safety and effectiveness. Their findings show the rapid alleviation of depressive, psychotic, and catatonic symptoms, with adverse effects typically mild and transient. However, this study underscores the need for more research in this population, as data on fetal and neonatal safety remain limited.Li et al. examined trends in ECT use in a psychiatric hospital in China over five years (2015-2020). Among 22,120 inpatients admitted during this period, 10% received ECT. Emergency department referral, unstable vital signs, and severe impairment in daily functioning as an independent were predictors of ECT use, highlighting ECT's role in cases requiring rapid symptom relief. This study also observed a decline in ECT utilisation, from 13.2% in 2015 to 5.7% in 2020, a trend consistent with global trends in ECT use.Patel et al. reported the case of a 35-year-old female patient with TRD and an implanted sacral neurostimulator for an overactive bladder, who safely received 3 sessions of ECT. At the same time, her device was placed in magnetic resonance imaging mode to prevent electric interference. This case showed that ECT can be an effective and safe treatment option, emphasising the importance of a thorough assessment and an individualized treatment plan in patients with neurostimulators. The case highlights the need for specific protocols for safely administering ECT in patients with implanted electronic devices. Pinchuk et al. described two cases of patients who developed status epilepticus after ECT, which resolved through restimulation. These reports support the view that ECT has anticonvulsant properties and underscore the need to develop clear clinical protocols for restimulation in cases where conventional interventions, such as propofol or lorazepam, fail to stop prolonged seizures. Zhou et al. explored knowledge, attitude towards, and willingness to undergo ECT among Chinese patients diagnosed with bipolar disorder through a questionnaire-based survey. Although knowledge levels were low and attitudes toward ECT were negative, patients expressed a surprisingly high willingness to undergo the treatment. These findings highlight the importance of clinician-led education to improve knowledge and acceptance of ECT.Geerts et al. conducted semi-structured clinical interviews with nine significant others of patients who received ECT to investigate caregivers' perspectives and experiences. Participants described the emotional burden of supporting patients with severe mental illness, and that a sense of hope accompanied the decision to commence ECT, but also with apprehension regarding potential side effects and a high sense of responsibility. Psychiatrists were identified as pivotal in fostering trust and providing accurate information. Given the crucial roles of significant others in treatment decision-making and patient adherence, this study highlights the importance of clear communication from psychiatrists, efforts to counter stigma, and the provision of experience-based information to support both patients and their families. In conclusion, this collection demonstrates the enduring significance of ECT in contemporary psychiatry, showcasing advances in its application while incorporating the perspectives of patients and caregivers. Together, these studies provide a comprehensive and contemporary appraisal of modern ECT practice.