Effects of ECT on platelet serotonin uptake in patients with major depression have been studied by Dalal and Lal in 1998. In this case–control study, platelet serotonin uptake was significantly raised after ECT, which was significantly lower in depression. This was indicative of the role of the serotonergic system in explaining effects of ECT. Jayakumar and Girish in 2001 tried to detect cerebral oedema, 1 day prior to the first ECT and at 2 hours after second ECT. Magnetic resonance imaging T2 relaxation time, which is an indicator of brain water content, was measured in the hippocampus and the thalamus of patients with depression receiving unilateral ECT; no differences were found. The authors concluded that ECT did not produce any brain oedema, and so ECT treatment may be considered safe. An animal model was used to study the effect of single ECT on dopamine autoreceptor down-regulation in the rat brain. The results suggested that ECT did not produce any acute and time dependent dopamine autoreceptor effects (Gangadhar et al. 1990).

Fractures of long bones are evident in many studies in unmodified type of ECT use. This was one main reason for advocating modified ECTs. Side effects associated with direct ECTs are not seen in modified type, although the adverse effects do occur in other areas which are evident in many studies. However, Gangadhar et al. (1983) found that ECT-treated patients reported fewer subjective side effects than imipramine-treated patients.

ECG abnormalities such as sinus tachycardia, ventricular premature beats, minor ST-T wave changes, increased amplitude, prolonged QTC intervals and elevated blood pressure lasting for more than 30 min are seen after ECT.

Cognitive side effects have been the main concern related to ECT. Jain et al. (2008) studied 373 patients who received ECT over 8 years. Of them, 56 (16 %) were more than 60 years of age; 66 % had a comorbid medical illness, and this was associated with higher risk of cognitive side effects. Again cognitive impairment has been found to be associated with ictal increase of blood pressure. 20 patients of depression with melancholic features were administered ECT and assessed before the first and after the second ECT. It was found that ictal systolic blood pressure was negatively correlated with the non-verbal memory score, but not with verbal score. This is hypothesized to be due to generalization of seizure or the stimulus administered.

Andrade et al. in 2000 studied 50 patients who had received bi-fronto temporal unmodified ECT. The results showed that 52 % of the patients complained of backache, of which 14 % had severe backache, and this was found to be more common in older patients. Gender, height or body weight did not predict the presence or severity of backache. One patient had vertebral fracture, which was not of serious kind. This study concluded that incidence of musculoskeletal morbidity is much less than it was thought earlier (20–40 % incidence in earlier studies).

Several studies have evaluated predictors of response in depression. Melancholic features, psychotic symptoms and catatonic symptoms are some of the clinical predictors of good response to ECT. Gupta et al. 2000 could identify duration of past episode, suicidal thought and somatic symptom that could distinguish good and poor responders of ECT in severe depressives. The effects of duration of the seizure and EEG characteristics have also been evaluated in Indian studies. A smaller post-seizure EEG fractal dimension after the first ECT predicted subsequent response to ECT in the course of depression (Gangadhar et al. 1999).

Cardiovascular changes that occur in ECTs pointed to potency of seizure and indicated the therapeutic efficacy of ECT in another study (Gangadhar et al. 2010). The authors concluded that ictal rate pressure product (RPP = heart rate × systolic blood pressure) can be an additional clinical measure, as ictal RPP increased when there was an adequate cerebral seizure (Gill et al. 2002). Saravanan et al. (2002) reported RPP response to ECT recorded under no Atropine condition predicted therapeutic response in depressive disorder.

Though medication-resistant patients respond to ECT, it predicts poor response to ECT in mania when compared with those in whom ECT was used as first-line treatment (Mukherjee et al. 1994). Symptoms of anger, irritability and suspiciousness are associated with poor response to ECT.

Studies on understanding the factors influencing patient choice of ECT provide a source of insight into the interplay between measures of response and perceived value of this treatment to patients, lending perspective to patient-centred quality improvement efforts.

In a study by Rajagopal et al. in 2012, patients who received ECT were found to be largely unaware of the procedure. Though most did not find the experience of ECT upsetting, sizeable proportions expressed dissatisfaction with aspects such as informed consent, fear of treatment and memory impairment. Although patients were mostly positive about ECT, ambivalent attitudes were also common, but clearly negative views were rare. Relatives were significantly likely to be more aware, more satisfied with the experience and have more favourable attitudes towards ECT, than patients (Grover et al. 2011; Rajagopal et al. 2012, 2013). Patients are many a times not well informed about ECT (Chakrabarti et al. 2010a).

The draft of the Mental Health Care Bill, 2011 (Thippeswamy et al. 2012), prohibits the administration of unmodified ECT. In several parts of the country, unmodified ECT still continues to be practiced owing to lack of anaesthesiologists, specialized equipment and cost factors. When viewed against the risk of musculoskeletal complications such as fractures, the immediate administration of ECT would be life saving in conditions such as catatonia. Rather than not giving ECT at all, giving a sub-optimal form of treatment may be justifiable in these circumstances. However, it is still debated if such a ban would be reasonable.

The draft also disallows the administration of ECTs in any form to minors. It has however been seen that ECT is the most effective form of treatment in certain situations—such as catatonia and severe suicidality. Several psychiatrists, in view of the fact that it may be a life-saving treatment in these conditions, have opposed such a blanket ban on ECTs in children and adolescents.

Research definitely shows much evidence for efficacy of ECT rather than its adverse effects. ECT treatment in recent decade is more sophisticated. The ECT machine has EEG and EKG monitoring, stimulus dose can be titrated and seizure may be measured even though debate on prescribing ECT is endless. However, in our opinion, the patient’s perspective has a great role in prescribing ECT, as I have seen patients with depression and relatives of patients of depression and schizophrenia in our setup asking for ECT treatment. Perhaps the perception of efficacy with ECT is no longer hidden to the public or misconception of brain damage or stigma with ECT is no more prevalent, but this needs further research in psychiatry setup and in the community as well. The term electroshock (earlier used) must be totally replaced by the term ECT while taking informed consent, even though at times patients and relatives do enquire about whether ECT is a shock therapy. Though unmodified ECT is better than no ECT, modified ECT must be practiced all over India as long as this option is available. For those who cannot afford ECT, treatments may be offered at a subsidized cost. Further research especially in the area of cognition and ECT is needed; double-blind trials on different aspects of efficacy and studies examining the mechanism of ECT will guide us towards a more conclusive opinion about use and practice of ECT.