Electroconvulsive Therapy in the United States: A 2022 Survey of Practice

Abstract

Objectives:

This study aimed to describe current United States (US) electroconvulsive therapy (ECT) practice, identify practice changes over time, and inform discussion of practice.

Method:

Our anonymous survey was open on SurveyMonkey.com from January to June 2022. We sent invitations to providers identified using a Medicare provider database, an advanced PubMed search function, and professional group listservs. Participants were instructed to submit one survey per ECT site. We examined frequency of responses, tabulated individual comments, and grouped data for comparison.

Results:

We received responses from 74 US practice sites encompassing 283 providers. Forty-nine percent (n=36) of respondents practiced at general academic medical centers, 23% (n=17) at general medical centers, 16% (n=12) at freestanding psychiatric hospitals, and 7% (n=5) at VA medical centers. Proportions of female (29%) and Black or African American (AA) (1%) ECT providers were markedly lower than proportions of female (60%) and Black or AA ECT patients (10%). The median number of treatments for a major depressive episode was 10. The preferred electrode placement was right unilateral (66%, n=45). The favored dosing strategy was seizure threshold titration. Quantitative outcome measures were used by 89% (n=66) of sites for depressive symptoms and 84% (n=62) for cognitive side effects.

Conclusions:

This survey is the first nationwide survey of ECT practice in nearly 40 years. Our results describe changes in practice over time and highlight the need to increase the number of female and Black or AA ECT providers. A comprehensive network of ECT sites could facilitate more frequent nationwide surveys.

Introduction:

Since the first use of electroconvulsive therapy (ECT) in 1938, there have been many advancements toward improved safety and efficacy in both the clinical and technical aspects of ECT.¹ Although guidelines have been published to promote standardized best practices in the United States (US),² without regular and comprehensive surveys of ECT clinical practice, it is difficult to share information about practice and to assess adherence to guidelines. Variation in the adoption of practice advancements can result in different efficacy and safety outcomes for patients.

The last comprehensive nationwide survey of ECT practice in the US was conducted in 1985 and was limited to private psychiatric hospitals.³ Nationwide surveys of ECT practice have since been conducted in the US, but on more specific topics or populations, such as maintenance ECT prevalence;⁴ ECT provider stimulation preferences;⁵ changes in ECT administration frequency over time;⁶ the characteristics of ECT psychiatrists;⁷ ECT practice in correctional facilities;⁸ and common barriers to ECT treatment.⁹ In addition to these nationwide efforts, several state-specific surveys have been conducted since 1985 including comprehensive surveys of practice in Nebraska,¹⁰ North Carolina,¹¹ and the New York metropolitan area;¹² ECT anesthesia practice in Pennsylvania;¹³ and factors influencing ECT referrals in Virginia.¹⁴ To increase awareness of and stimulate discussion about contemporary ECT practice, we developed a comprehensive questionnaire to collect information on the clinical, social, and technical aspects of ECT practice nationwide.

Method

We developed and distributed a 77-question survey about ECT practice that included 38 multiple choice questions, 20 free response questions, and 19 slider scale questions. It was published online through the SurveyMonkey platform on January 27, 2022 and remained open through June 10, 2022. Responses were received from practitioners worldwide. This paper focuses only on US respondents. Instructions informed participants that all answers were anonymous, to answer all questions as thoroughly as possible, and to submit only one survey response per ECT practice site. Respondents were instructed to use data where possible, but if none were available to make their best estimate. See supplemental file containing the survey.

Participants were recruited via three methods. First, we contacted groups likely to have ECT practitioners as members including the International Society for ECT and Neurostimulation (ISEN), the International Consortium on the Genetics of Electroconvulsive Therapy and Severe Depressive Disorders (GenECT-ic), the Global ECT-MRI Research Collaboration (GEMRIC), the International Society for Bipolar Disorders (ISBD), and the National Network of Depression Centers Neuromodulation Task Group and obtained permission to contact members. Email invitations were sent to members of these groups. Our second method involved searching the 2019 Medicare Physician & Other Practitioners – by Provider and Service registry for ECT provider addresses using the ECT Medicare code 90870. All providers listed were mailed postcard invitations to the survey. Thirdly, we harvested a list of potential ECT provider emails from PubMed by conducting a search using the terms “ECT” and “electroconvulsive therapy”, exported our search results as a text file in the MEDLINE format, and used the website ConvertCSV.com to pull a list of corresponding author emails.¹⁵ We developed an Excel (Microsoft, Redmond, WA, USA) Visual Basic for Applications script to email invitations addressed to each author. We recorded all responses from US sites, and data were examined for frequency of specific responses, tabulated by individual comments for qualitative review, and grouped by demographic factors for comparisons. The data were analyzed using R statistical software (v3.6.3; R Core Team 2020). Descriptive statistics of medians and percentages to reflect response frequency are reported. Sample size across some questions differed as respondents did not answer all questions. The survey was reviewed by the National Institutes of Health (NIH) Office of Intramural Research Institutional Review Board (IRB) which determined that it did not require full IRB review or approval because it did not qualify as human subjects research.

Results

We received responses from 74 US ECT practice sites accounting for a total of 283 providers. Based on the Substance Abuse and Mental Health Services Administration’s (SAMSHA) 2020 National Mental Health Services Survey, which identified 498 facilities offering ECT, our results reflect approximately 15% of US ECT sites.¹⁶

Facility Type and Resources

Forty-nine percent (n=36) of respondents were from general academic medical centers, 23% (n=17) from general medical centers, 16% (n=12) from freestanding psychiatric hospitals, and 7% (n=5) from Veterans Affairs (VA) medical centers. Ninety-three percent (n=69) of these facilities offered both inpatient and outpatient ECT. Sixty-one percent (n=45) of sites treated children and/or adolescents as well as adults.

For facility resources, 46% (n=34) of sites had designated spaces for ECT. Sites without a specified ECT space most often used the Post Anesthesia Care Unit (PACU) (28%, n=21). Concerning staffing, 66% (n=49) of sites had dedicated ECT nursing staff; 45% (n=33) had dedicated administrative staff, and 35% (n=26) had dedicated anesthesia staff. Most facilities had an attending anesthesiologist available (86%, n=64). These attendings worked either without another specialist (31%, n=23), paired with a nurse anesthetist (29%, n=22), supervising an anesthesiology resident (8%, n=6), or alongside both a nurse anesthetist and an anesthesiology resident (18%, n=13). Fourteen percent of sites did not have an attending anesthesiologist available (n=10); 12% had a nurse anesthetists alone (n=9), and 1% had a nurse anesthetist and anesthesiology resident pair (n=1).

The most frequently used ECT device was the Thymatron^® System IV (51%, n=38) followed by the MECTA spECTrum 5000Q^® (34%, n=25) and the MECTA Σigma^™ (20%, n=15). Eighteen percent (n=13) of respondents used multiple devices.

Provider Characteristics

ECT sites had a median of 3 providers with a median age of 49 years. Twenty-nine percent (n=82) of US providers identified as female and 71% (n=201) as male. No providers identified as nonbinary. The ECT practitioners surveyed were predominantly White (73%, n=207). Nineteen percent (n=53) of providers identified as Asian, 1% (n=3) as Black/African American, 1% (n=3) as American Indian or Alaska Native, and 5% (n=13) as multi-racial. Two providers did not identify with any racial or ethnic category provided. US provider racial and ethnic identity information are presented in comparison to patient characteristics in Figure 1.

Figure 1.

Percent comparisons of racial and ethnic identities of ECT patients and providers. Patient values are medians. ECT provider values are totals. Demographic categories are displayed in descending order by median percent of patients. Patients and providers could identify with the ethnic identity Hispanic or Latino alone or paired with another racial identity. A multiracial identity was an option only for ECT providers.

Patient Characteristics

Respondents were asked to estimate characteristics of their respective patient populations including age; percent identified with a particular gender, racial, or ethnic category; and percent with specific diagnoses. We summarize this information below using group medians for all reported values. A median of 125 patients were treated per site per year with a median patient age of 50 years. Sixty percent of patients were described as female. ECT patients were described as White (80%), Asian (45%), and Black/African American (10%). Some sites (n=16) reported treating American Indian or Alaska Native, or Native Hawaiian or Pacific Islander patients. However, because there were so few, the median reported percent of these patients was 0%.

The most common diagnosis was major depressive disorder (MDD) (62%) followed by bipolar disorder (BD) (20%), catatonia alone (10%), and psychosis alone (10%). Of those patients treated for MDD, 22% were being treated for psychotic depression. Of the patients receiving treatment for BD, 10% were treated for manic episodes. Twenty-six percent (n=19) of ECT sites had treated status epilepticus with a median of 1 patient per year. Prior to ECT referral, a median of 12% of patients had received transcranial magnetic stimulation (TMS) or another neurostimulation approach, and 5% had tried ketamine infusions or esketamine.

Administration of ECT

For treating a major depressive episode (MDE), including patients with MDD or bipolar depression, 85% (n=63) of sites conducted 3 sessions per week with a median of 10 sessions for a total course. Seven percent (n=5) of respondents conducted sessions twice per week and 5% (n=4) administered 2 sessions per week for outpatients and 3 for inpatients. Almost all respondents (97%, n=72) required an average of 12 treatments with minimal or no response before a patient was considered a non-responder. The median number of treatments with little or no response before adjusting treatment technique was six. The most common technique changes to address nonresponse were switching electrode placement from right unilateral (RUL) to bitemporal (BT) (65%, n=48) or bifrontal (BF) (30%, n=22) or changing pulse width from ultra-brief (UB) (≤0.3 ms) to brief (0.5-1.0 ms) (30%, n=22). Following a full course, all respondents described conducting continuation and maintenance ECT for patients who were willing and able. The median reported percent of patients who received continuation and maintenance ECT was 51%. When tapering continuation ECT, 42% of sites (n=31) followed a double-time tapering schedule (weekly, bimonthly, monthly…) and 36% (n=27) followed a weekly taper (weekly, every 2 weeks, every 3 weeks…).

When choosing an original electrode placement to treat a MDE, RUL (66%, n=45) was most common. For all other psychiatric indications sites preferred BT electrode placement. Electrode placement preferences by diagnosis are displayed in Table 1. For each electrode configuration, ECT practitioners were asked their preferred dosing strategy and pulse width. Preferred pulse widths differed by electrode placement. Seizure threshold titration was the most common dosing strategy for all electrode placements. Dosing strategy and pulse width preferences by electrode placement are presented in Tables 2 and 3, respectively. When seizure threshold titration was used for dosing, the multiple of threshold applied for therapeutic dose seizures differed across electrode placements. The median multiple for BF and BT was 2 times, while for RUL it was 6 times threshold.

Table 1.

Percent of ECT Sites Using Specific Electrode Placements by Diagnosis

Electrode Placement	Diagnoses
	Major Depressive Episode1	Mania	Catatonia	Schizophrenia
Right Unilateral	66% (45)	19% (14)	7% (5)	26% (19)
Bifrontal	16% (11)	21% (15)	12% (9)	14% (10)
Bitemporal	13% (9)	58% (41)	80% (59)	58% (42)
Left Anterior Right Temporal	4% (3)	1% (1)	0% (0)	1% (1)

Because of rounding, percentages do not sum to 100%.

¹Includes patients with unipolar major depression (MDD) and bipolar depression

Table 2.

Percent of ECT Sites Using Specific Dosing Strategies by Electrode Placement

Dosing Strategy	Electrode Placement
	Right Unilateral	Bitemporal	Bifrontal	Left Anterior Right Temporal
Age Method	13% (9)	7% (5)	7% (5)	3% (2)
Half-Age Method	3% (2)	26% (18)	17% (12)	3% (2)
Seizure Threshold Titration	84% (59)	64% (45)	36% (25)	12% (9)
Do not use placement	0% (0)	5% (2)	39% (27)	79% (58)

Because of rounding, percentages do not sum to 100%

Table 3.

Percent of ECT Sites Using Specific Pulse Widths by Electrode Placement

Pulse Width	Electrode Placement
	Right Unilateral	Bitemporal	Bifrontal	Left Anterior Right Temporal
≤0.3 ms	77% (55)	7% (5)	4% (3)	1% (1)
0.5 ms	18% (13)	55% (40)	44% (32)	12% (9)
≥1 ms	7% (5)	32% (23)	18% (13)	5% (4)
Do not use placement	0% (0)	7% (5)	33% (24)	81% (59)

Because of rounding, percentages do not sum to 100%

Respondents were asked about anesthesia practice during ECT administration. When considering the frequency of drugs used either in combination or alone, methohexital (81%, n=60) was most common, followed by etomidate (39%, n=29), propofol (18%, n=13), ketamine (12%, n=9), and remifentanil (8%, n=6). All sites used succinylcholine/suxamethonium for neuromuscular blockade. Fifty-three percent (n=39) of sites routinely used pre-medications in addition to anesthetics or neuromuscular blockers. Most employed a single drug (62%, n=24) rather than a combination (38%, n=15). Either alone or combined, sites administered glycopyrrolate (33%, n=24), ketorolac (33%, n=24), beta-blockers (15%, n=11), and atropine (3%, n=2).

Survey participants were asked about methods for managing difficulty inducing seizures. Switching anesthetics (77%, n=57) or administering intravenous caffeine (51%, n=38) were the most common responses. Other methods included doubling stimulation dose (36%, n=27), increasing hydration (24%, n=18), switching to RUL placement (22%, n=16), or switching to UB pulse width (19%, n=14). When asked about benefits and negative effects of sub-seizure stimulation, 36% (n=27) noted no benefits or negative effects, 11% (n=8) noted possible benefits, and 1% (n=1) described bradycardia and asystole as negative effects. All sites employed a bite block during the ECT procedure with 93% (n=69) using an ECT device manufacturer-provided bite block, while 4% (n=3) used another purchased bite block, and 3% (n=2) used rolls of gauze.

Documentation and Monitoring

Most commonly, ECT facilities obtained separate ECT and anesthesia consents for the entire treatment series (41%, n=30). The most frequent alternative was obtaining a single consent for ECT and anesthesia for the whole treatment series (38%, n=28). Other sites obtained consent for each individual treatment, with 11% of sites (n=8) using a separate consent for anesthesia and 10% (n=7) of sites using a combined consent.

Most sites described using a quantitative depression outcome measure (89%, n=66). The most popular measure was the Patient Health Questionnaire 9 (PHQ9) (38%, n=28), followed by the Montgomery-Asberg Depression Rating Scale (MADRS) (26%, n=19), Inventory of Depressive Symptomatology/Quick Inventory of Depressive Symptomatology (IDS/QIDS) (20%, n=15), Beck Depression Inventory (BDI) (11%, n=8), Clinical Global Impression Scale (CGI) (9%, n=7), and the Hamilton Depression Rating scale (HAM-D) including the 17 (7%, n=5), 21 (3%, n=2), and 24 (5%, n=4) item versions. Facilities most often administered their depression measures at baseline, weekly and at end of course (38%, n=28). Sixteen percent (n=12) of sites used outcome measures only at baseline and at end of course, while 20% (n=15) of sites administered their measure at baseline, after each treatment, and at end of course.

A rating scale for cognitive side effects was used by 84% (n=62) of sites. The Montreal Cognitive Assessment (MoCA) was most often employed (61%, n=38), followed by the Mini-Mental State Examination (MMSE) (25%, n=22), and the Saint Louis University Mental Status (SLUMS) examination (19%, n=12). Cognitive side effect scales were administered at baseline and at end of course (50%, n=31); at baseline, weekly, and end of course (39%, n=24), or at baseline, after each treatment, and end of course (13%, n=8).

Barriers to Delivering ECT

The most common barriers to delivering ECT were lack of a family member or friend for escort to outpatient treatments (74%, n=55) and lack of transportation (72%, n=53). Stigma was the third most common barrier (62%, n=46). Other notable barriers included an inability to convince the patient that ECT is safe (34%, n=25), issues with insurance or financial restrictions (32%, n=24), and lack of appointments available internally (19%, n=14). Local laws and regulations were not listed as a barrier option; however, several respondents noted barriers related to strict regulations and laws in their specific state.

Discussion

This survey is the first published, nationwide, comprehensive survey of US ECT practice since that of Levy and Albrecht published in 1985.³ It provides updated information on ECT practice methods, facility resources, and patient and provider demographics across the US.

ECT Practice Over Time

The median of 3 providers per site is consistent with Levy and Albrecht’s 1985 results showing most hospitals had between 2 and 5 psychiatrists administering ECT.³ However, our findings suggest a shift in ECT anesthesia staffing. In Levy and Albrecht’s survey, 40% of respondents reported that the attending psychiatrist administered anesthetic agents, and only 48% of their surveyed facilities employed anesthesiologists.³ Eighty-six percent of our survey sample had an attending anesthesiologist available with 36% of these facilities also pairing nurse anesthetists with attendings.

Most sites in our sample (61%) described providing ECT to children and/or adolescents while a majority of Levy and Albrecht’s respondents (54%) limited ECT to patients over 18 years of age.³ The most common methods of tracking patient progress also appear to have shifted. Most of our respondents administered a quantitative depression outcome measure (89%). In contrast, virtually all facilities (97%) in Levy and Albrecht’s sample relied on the opinion of the attending psychiatrist to determine treatment response, while only 12% of facilities incorporated an outcome measure.³ Levy and Albrecht’s survey did not include an item regarding assessment of cognitive side effects.³

The widespread application of mood and cognitive outcome measures in our sample may represent an increase in the standardization of clinical practice and attention to patient safety. Administering a formal neuropsychological assessment is in accordance with both American Psychological Association (APA) and Food and Drug Administration (FDA) guidance regarding cognitive status monitoring during an ECT course.^2,17

Regarding anesthetic choice, our findings are consistent with previous surveys indicating the predominant use of methohexital.^3,12 For pre-medications, only 3% of our respondents regularly administered atropine, while it was the preferred pre-medication for Levy and Albrecht’s respondents (82%).³

Performing continuation and maintenance ECT was more common in our survey sample than previous surveys. All our respondents offered continuation and maintenance ECT to patients who were willing and able; while only 64% of Levy and Albrecht’s sample performed continuation and maintenance ECT.³

Our findings with respect to electrode placement and dosing strategy preferences are difficult to compare with previous findings. We asked respondents about their preferred electrode configurations for treating specific diagnoses while previous surveys asked for a general preference.^5,12 Also, prior surveys provided only unilateral (UL) and bilateral (BL) electrode placements as treatment options and did not further differentiate BL placement into BT and BF. Acknowledging these constraints, both prior surveys showed a preference toward BL electrode placement. Fifty-two percent of providers in Farah and McCall’s 1993 survey of US ECT dosing practices and 79% of respondents to Prudic and colleagues’ 2001 survey of the New York Metropolitan Area favored BL.^5,12 Given that our respondents favored a RUL placement for the treatment of a MDE, which includes MDD, the predominant diagnosis of patients treated with ECT, our results suggest a general shift over time from BL to RUL placement, although this was not observed for diagnoses other than MDD.

Comparing our findings concerning dosing strategy preferences to prior surveys is limited by the fact that we asked respondents for their preferred dosing strategy for individual electrode placements while prior authors asked for a general preference.^5,12 The majority of Prudic and colleagues’ respondents employed a seizure threshold titration method (55%) while Farah and McCall’s survey responders most often used a formula (49%) or seizure threshold titration (39%) with some providers preferring a fixed-dose method (12%).^5,12 In contrast to Farah and McCall’s results, and consistent with more recent APA guidelines, no sites from our sample most often used a fixed dose method regardless of electrode placement.^2,5 Furthermore, irrespective of placement, our respondents preferred seizure threshold titration over formula-based dosing methods.

Regarding barriers to ECT delivery, Wilkinson and colleagues’ 2021 survey of barriers to ECT implementation found that when expanding an existing ECT service, a lack of physical space, patient stigma, and transportation issues were key limitations.⁹ Similarly, the top three barriers reported by our respondents were, in descending order, lack of an escort, no transportation and stigma. The lack of transportation and/or escort barrier is common to outpatient procedures that require general anesthesia.¹⁸ While not specific to outpatient ECT, ECT poses greater challenges because it is often a serial procedure and can induce cognitive impairment beyond that experienced with general anesthesia. For those without family or friends to escort and transport, obtaining medical transportation and escort is often expensive as they are usually not covered by insurance. Potential solutions to this problem include switching to inpatient treatment if it can be covered by insurance, finding insurance coverage in some states through Medicaid, hiring a medical escort through a home health care company if affordable, and finding volunteer escorts and transportation through local nonprofit groups.¹⁸

Regarding local regulations as a barrier to ECT, it was not listed as a response option, which may have limited our ability to detect this as a significant barrier. It is noteworthy that states vary considerably in regulations pertaining to patient age, provider qualifications and informed consent.^19,20 Future surveys should consider listing this as a response option.

Provider and Patient Demographics

Since the last survey of ECT provider demographic characteristics in 1998,⁷ the proportion of female ECT providers has increased more than four-fold from 7% to 29%. However, this proportion remains well below the proportion of ECT patients (60%) and psychiatrists (62%) who are female.²¹ Regarding the ethnic or racial identities of ECT providers, prior research grouped all minoritized racial and ethnic identities as “non-white” making comparisons difficult.⁷ Notwithstanding this oversimplification, our survey showed a higher proportion of ECT practitioners identified with a racial or ethnic identity other than White (23%) than Herman and colleagues’ 1998 survey (13%).⁷ However, there remains a clear inequity when comparing the proportion of Black/African American ECT providers (1%) to the proportion of Black/African American ECT patients (10%) and the proportion of Back/African American psychiatrists (4.4%).^21,22 Given evidence that Black/African American patients are less likely than White patients to receive ECT and the role of racial bias in decisions that determine ECT referral, the underrepresentation of Black/African American psychiatrists among ECT practitioners likely contributes to racial disparities in ECT treatment.^23,24 Efforts to enhance Black/African American representation among ECT providers could, therefore, improve racial disparities in the provision of ECT and ultimately improve health outcomes for Black/African American patients.

Strengths and Limitations

A primary strength of this study is that it is the first published, nationwide, comprehensive survey of US ECT practice for nearly 40 years, filling a large gap in the literature regarding the current characteristics of US ECT practice. The nationwide scope of the study provides a more accurate picture of US practice than regional studies. Additionally, the survey was comprehensive, including questions about demographics, practice methods, resources, and documentation to provide a breadth of knowledge. The survey was also anonymous, which can minimize a bias toward answering questions to align with standard or recommended practice.

There are study limitations that require discussion. Firstly, our survey sample is a small proportion (15%) of the total number of US ECT sites. Secondly, we could not calculate an overall survey response rate. Only one of our survey distribution methods, sending postcards to providers in the 2019 Medicare database, allowed for a response rate calculation. This response rate was low (2%). Our two other survey distribution methods, emailing providers from relevant groups and emailing a list of providers generated from PubMed, did not allow for response rate calculations. Thirdly, nearly half of our respondents practiced at academically affiliated general medical centers, possibly skewing our results toward practice at academic sites. Fourthly, the Medicare Provider Utilization and Payment Database only includes providers who bill Medicare, excluding providers who do not bill Medicare, such as VA providers.⁹ Fifthly, participants were instructed to use data for answers wherever possible, but if no data were available, to make their best estimate. Consequently, some responses were based on estimates rather than verifiable data. Sixthly, our comparisons to previous surveys were limited by differences in populations surveyed. For example, the Levy and Albrecht 1985 survey sample included only private psychiatric hospitals, while only 16% of facilities in our survey were private psychiatric hospitals.³ Therefore, some differences in responses may reflect differences in practice between freestanding psychiatric hospitals and academic medical centers or other facilities, rather than changes in practice over time. This issue also emerged when comparing our results to those in regional studies. Divergent results could be attributed to regional differences rather than changes in practice over time. Finally, in the analysis of the collected data, answers to open ended questions could not be easily grouped into frequently used categories, so only data that could be efficiently captured and fit into common categories are reported.

Conclusions

Among our notable study findings, ECT provider and patient characteristics data reveal a lack of female and Black/African American providers relative to proportions of female and Black/African American psychiatrists generally and to the proportion of female and Black/African American ECT patients. Nearly all sites offered outpatient ECT. Approximately half of patients received continuation/maintenance treatment. ECT technique for treating patients with a MDE was fairly uniform across practices with a majority of sites using RUL electrode placement and seizure threshold titration for dosing. Most sites used an UB pulse width when using RUL placement. Most, but not all sites, used quantitative outcome measures to track depressive symptoms and cognitive side effects. The most common barriers to delivering ECT were related to escort availability and transportation.

Our findings suggest several future directions. Firstly, the nearly forty-year gap since the last comprehensive nationwide survey of US ECT practice calls for more frequent and regular surveys to assess practice. This large gap makes it difficult to track changes in practice, assess adherence to guidelines, and build off existing practice to improve methods and inform guidelines. Our success rate in obtaining data from no more than 15% of all US ECT practice sites suggests that surveying US ECT practitioners is a difficult task. This difficulty likely contributes to the dearth of surveys. In countries such as Denmark and Spain where there are comprehensive government registries of psychiatric facilities or ECT practice sites, surveyors have obtained data from all or nearly all sites.^25,26 Therefore, a second future direction is to establish a nationwide network of ECT practice sites to facilitate surveys and communication about ECT practice. An organized network could facilitate communication between providers and enable easier collection of data through surveys and studies. A network would also assist in assessing progress toward enhancing the diversity of ECT providers and allow guidelines to be communicated to all providers at once to encourage the safest and most effective practices. One model for such a network is the Scottish Electroconvulsive Therapy Accreditation Network (SEAN) that was formed in 1996.^27,28 Thirdly, the underrepresentation of women and minoritized racial and ethnic groups among ECT providers demonstrates a need for further initiative in increasing diversity among providers. While the gaps have gotten smaller, our data demonstrate there is still work to be done. Finally, to address transportation barriers to ECT delivery, patient advocacy efforts could target the provision of safe escort and transportation for outpatient ECT by healthcare systems, insurance companies and governmental agencies.