Electro-convulsive therapy (ECT) remains an important, potentially life-saving tool in the treatment of depression. Its efficacy in depression is second to none, yet it remains underused by psychiatrists. It is a very safe treatment, safer than antidepressants in some patients. Adverse effects, particularly memory impairment, are increasingly better managed with improved treatment parameters, such as the use of high-dose unilateral ECT. National guidelines support the use of ECT, although not as robustly as the Royal College of Psychiatrists, which recommends earlier consideration and use of ECT than is currently the case. ECT was the first neuromodulation treatment for depression. Several others have since been developed, supported by a variable degree and quality of evidence.