Imagine hearing voices that will not stop — day after day, year after year — until you can no longer tell what is real. You cycle in and out of psychiatric hospitals, trying one medication after another, hoping the next prescription will finally quiet the noise.
That was the experience of a man with severe schizophrenia described in a case report. He was repeatedly hospitalized for worsening psychosis. Doctors tried nearly every medication available, but the voices never stopped — even with the most effective options. He faced a lifetime of disability.
Eventually, after multiple failed treatments, he was referred for electroconvulsive therapy, known as ECT. Only then did the voices quiet. He returned to work for the first time in years, regaining function he had lost to uncontrolled illness.
Cases like this are not rare. Yet for patients whose illness is severe enough to warrant ECT, access often comes too late — if it comes at all.
ECT is one of the most effective and fastest-acting treatments available in psychiatry. It is used for depression, bipolar disorder, psychotic illness, and catatonia. Clinical guidelines recommend ECT when symptoms are severe, treatment-resistant, or require rapid response. A recent New England Journal of Medicine review reports response rates of 60% to 80% in treatment-resistant depression, with remission in approximately half of patients.
Despite strong evidence, ECT remains one of the most underused treatments in psychiatry. In my clinical training, I have rarely seen ECT used, and more often see patients continue to suffer when access to it is limited.
So why aren’t more patients getting ECT?
Three factors stand out: stigma, limited availability, and cost.
Stigma still shapes perception
ECT carries a persistent cultural stigma rooted in outdated film portrayals of the procedure. Films like The Snake Pit (1948) and One Flew Over the Cuckoo’s Nest (1975) depicted the treatment as forced, painful, and performed on conscious patients.
That’s not what ECT looks like today — but those images still shape how people think about it. Modern ECT is performed under general anesthesia with careful monitoring and muscle relaxation, and treatments last only minutes.
More recently, even international policy discussions have reflected ongoing debate about ECT, with some guidance emphasizing caution and restriction — while psychiatric organizations warn that such framing may reinforce stigma and limit access to evidence-based care.
Access depends on where you are
For many patients, access to ECT may be simply unavailable; ECT is not used in 9 out of 10 U.S. hospitals. Over time, availability has declined, driven more by a reduction in the number of hospitals providing the service rather than decreased use within those that still do.
Location also matters. Smaller, rural, and non-teaching facilities are less likely to offer ECT, and trained specialists can be difficult to find in these settings.
In practice, whether a patient receives ECT often depends less on clinical need and more on where they happen to receive care.
Is ECT really too expensive?
Cost is another frequently cited barrier. At first glance, ECT can seem expensive — especially when delivered during an acute hospitalization. One analysis found that hospitalizations involving ECT were associated with longer stays and higher inpatient costs.
However, that does not mean ECT itself is driving those costs. These hospitalizations reflect patients with severe, uncontrolled illness requiring stabilization, not admissions primarily for ECT. ECT is often introduced after other treatments have not led to improvement, which can extend the course of hospitalization.
In reality, the procedure and anesthesia account for a small portion of total expenses, while most costs are tied to the hospitalization itself. Other analyses show that hospital stays make up the vast majority of total costs, accounting for roughly 90%.
In other words, the cost comes from the illness — and how long it takes to stabilize it — not the treatment itself.
This raises a question: are we overestimating the cost of ECT, or underestimating the cost of not using it sooner?
When ECT stabilizes severe illness, it can reduce long-term healthcare spending — not just by improving symptoms, but by preventing repeated hospitalizations. Patients who continue maintenance ECT have lower risks of psychiatric readmission and lower overall healthcare costs.
What should patients expect?
ECT is not without side effects. Some patients experience short-term memory difficulties or temporary confusion following treatment, but these are typically brief and resolve within days. Serious complications are rare.
For many patients, the alternative is far worse: years of uncontrolled symptoms, repeated hospitalizations, and lives limited by disability.
ECT has been saving lives for decades. It can restore functioning, reduce hospitalizations, and offer hope to patients who have exhausted nearly every other treatment option.
The question is no longer whether ECT works.
The real question is why patients who could benefit from it still cannot access it.
Haley Brennan is an MD-MPH candidate at the University of Miami Miller School of Medicine with interests in psychiatry, public health, and mental health care access.
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