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Objective The effectiveness of ECT under naturalistic conditions has not been well-studied. The current study aimed to 1) characterize a naturalistic sample of ECT patients; and 2) examine the long-term outcomes of ECT on depressive symptoms (Beck Depression Inventory-II; BDI-II) and functional disability symptoms (WHO Disability Assessment Schedule 2.0) in this sample. Methods Participants were adults who received ECT for a major depressive episode at an ambulatory ECT clinic between September 2010 and November 2020. Clinical and cognitive assessments were completed at baseline ( n = 100), mid-ECT ( n = 94), 2–4 weeks post-ECT ( n = 64), 6-months post-ECT ( n = 34), and 12-months post-ECT ( n = 19). Results At baseline, participants had severe levels of depressive symptoms (BDI-II: M = 41.0, SD = 9.4), and 62.9% screened positive for multiple psychiatric diagnoses on the MINI International Neuropsychiatric Interview. Depressive symptoms ( F(4,49.1) = 49.92, P  < 0.001) and disability symptoms ( F(3,40.72) = 12.30, P  < 0.001) improved significantly following ECT, and this was maintained at 12-months follow-up. Improvement in depressive symptoms trended towards significantly predicting reduction in disability symptoms from baseline to post-ECT, ( F(1,56) = 3.67, P  = 0.061). Although our clinical remission rate of 27% (BDI-II score [Formula: see text] 13 and [Formula: see text] 50% improvement) and overall response rate of 41.3% ([Formula: see text]50% improvement in BDI-II score) were lower than the rates reported in the extant RCT and community ECT literature, 36% of those treated with ECT were lost to follow-up and did not complete post-ECT rating scales. At baseline, remitters had significantly fewer psychiatric comorbidities, lower BDI-II scores, and lower disability symptoms than non-responders ( P < 0.05). Conclusions Participants were severely symptomatic and clinically complex. ECT was effective at reducing depressive symptoms and functional disability in this heterogeneous sample. Although a large amount of missing data may have distorted our calculated response/remission rates, it is also likely that clinical heterogeneity and severity contribute to lower-than-expected remission and response rates to ECT.

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