Electroconvulsive therapy (ECT) is a safe and effective medical treatment, yet provision varies internationally. We provide an up-to-date review of ECT practice in Nordic and western European countries.

European experts contributed data from peer-reviewed literature, governmental publications, unpublished administrative datasets, and hitherto unpublished surveys. The primary outcome was the number of individuals treated with ECT in each country per year. Primary analysis compared the annual treated person rate per million population in the most recent year since 2015 for which data were available. Secondary analysis compared trends in rates over 25 years, in countries for which a reliable outcome was available at two or more time points.

Across 15 countries, 12 had data meeting primary analysis criteria. Of these, all Nordic countries had annual treated patient rates per million population over 200, Italy 2.7, and other western European countries between 30 and 100. German-, Dutch-, and French-speaking countries saw increases in ECT use over 25 years, while English-speaking countries exhibited declines. Unilateral placement varied from 16% of treatments in the United Kingdom to 79% in Norway. Everywhere, most ECT was given for depressive episodes.

Although the optimal rate of use is unknown, widely differing rates across European nations suggest ECT is underused in some high-income countries, depriving patients of vital medical care. The European ECT community must support the development of reliable data collection on usage across the continent and service improvement where provision is underdeveloped, to ensure appropriate treatment is offered to all patients for whom it is indicated.

Severe depression can be a life-threatening disorder, especially in elderly patients. A fast-acting treatment is crucial for this group. Electroconvulsive therapy (ECT) may work faster than medication.

To compare the speed of remission using ECT v. medication in elderly in-patients.

The speed of remission in in-patients with a DSM-IV diagnosis of major depression (baseline MADRS score $20) was compared between 47 participants (mean age 74.0 years, s.d. = 7.4) from an ECT randomised controlled trial (RCT) and 81 participants (mean age 72.2 years, s.d. = 7.6) from a medication RCT (nortriptyline v. venlafaxine).

Mean time to remission was 3.1 weeks (s.d. = 1.1) for the ECT group and 4.0 weeks (s.d. = 1.0) for the medication group; the adjusted hazard ratio for remission within 5 weeks (ECT v. medication) was 3.4 (95% CI 1.9–6.2).

Considering the substantially higher speed of remission, ECT deserves a more prominent position in the treatment of elderly patients with severe depression.