Electroconvulsive therapy for the treatment of depression: from convulsive treatment to precision neuromodulation

INTRODUCTION: ECT remains one of the most effective treatments for severe depression, including psychotic and treatment-resistant presentations and high-acuity cases requiring rapid response. This review examines ECT as a parameter-sensitive neuromodulation procedure rather than a fixed convulsive treatment. AREAS COVERED: We review historical development, clinical efficacy, safety, relapse prevention, and mechanistic models involving seizure induction, electric-field effects, inhibitory plasticity, neurochemical and neuroendocrine signaling, network change, and postictal brain states. The literature was identified through searches of PubMed/MEDLINE, Web of Science, Scopus, IEEE Xplore, and Google Scholar from database inception to June 2026, supplemented by reference-list screening, with evidence evaluated according to study design, clinical relevance, and technological maturity. Established components of contemporary ECT practice are distinguished from near-term optimization strategies and experimental technologies. EXPERT OPINION: Precision ECT should be regarded as an emerging framework rather than an established standard of care. Patient-specific electric-field modeling, biomarker-guided dosing, amplitude optimization, and adaptive stimulation are promising strategies for improving the therapeutic index, but require prospective validation against optimized standard ECT using clinical, cognitive, and patient-reported outcomes.