between different countries, different hospitals, and different psychiatrists. international practice varies considerably from widespread use of the therapy in many western countries to a small minority of countries that do not use ect at all, such as slovenia. about 70 percent of ect patients are women. this may be because women are more likely to be diagnosed with depression. older and more affluent patients are also more likely to receive ect. the use of ect is not as common in ethnic minorities. in sweden, which has a complete register of all ect treatments in the country, in 2013 the rate of persons treated in that year per 100,000 inhabitants was 41. almost the same rate had already been present in 1975 with 42 patients per 100,000 inhabitants. united states ect became popular in the us in the 1940s. at the time, psychiatric hospitals were overrun with patients whom doctors were desperate to treat and cure. whereas lobotomies would reduce a patient to a more manageable submissive state, ect helped to improve mood in those with severe depression. a survey of psychiatric practice in the late 1980s found that an estimated 100,000 people received ect annually, with wide variation between metropolitan statistical areas. accurate statistics about the frequency, context and circumstances of ect in the us are difficult to obtain because only a few states have reporting laws that require the treating facility to supply state authorities with this information. in 13 of the 50 states, the practice of ect is regulated by law. in the mid-1990s in texas, ect was used in about one third of psychiatric facilities and given to about 1,650 people annually. usage of ect has since declined slightly; in 2000–01 ect was given to about 1,500 people aged from 16 to 97 (in texas it is illegal to give ect to anyone under sixteen). ect is more commonly used in private psychiatric hospitals than in public hospitals, and minority patients are underrepresented in the ect statistics. in the united states, ect is usually given three times a week; in the united kingdom, it is usually given twice a week. occasionally it is given on a daily basis. a course usually consists of 6–12 treatments, but may be more or fewer. following a course of ect some patients may be given continuation or maintenance ect with further treatments at weekly, fortnightly or monthly intervals. a few psychiatrists in the us use multiple-monitored ect (mmect), where patients receive more than one treatment per anesthetic. electroconvulsive therapy is not a required subject in us medical schools and not a required skill in psychiatric residency training. privileging for ect practice at institutions is a local option: no national certification standards are established, and no ect-specific continuing training experiences are required of ect practitioners. united kingdom in the uk in 1980, an estimated 50,000 people received ect annually, with use declining steadily since then to about 12,000 per annum in 2002. it is still used in nearly all psychiatric hospitals, with a survey of ect use from 2002 finding that 71 percent of patients were women and 46 percent were over 65 years of age. eighty-one percent had a diagnosis of mood disorder; schizophrenia was the next most common diagnosis. sixteen percent were treated without their consent. in 2003, the national institute for health and care excellence, a government body which was set up to standardize treatment throughout the national health service in england and wales, issued guidance on the use of ect. its use was recommended "only to achieve rapid and short-term improvement of severe symptoms after an adequate trial of treatment options has proven ineffective and/or when the condition is considered to be potentially life-threatening in individuals with severe depressive illness, catatonia or a prolonged manic episode". the guidance received a mixed reception. it was welcomed by an editorial in the british medical journal but the royal college of psychiatrists launched an unsuccessful appeal. the nice guidance, as the british medical journal editorial points out, is only a policy statement and psychiatrists may deviate from it if they see fit. adherence to standards has not been universal in the past. a survey of ect use in 1980 found that more than half of ect clinics failed to meet minimum standards set by the royal college of psychiatrists, with a later survey in 1998 finding that minimum standards were largely adhered to, but that two-thirds of clinics still fell short of current guidelines, particularly in the training and supervision of junior doctors involved in the procedure. a voluntary accreditation scheme, ectas, was set up in 2004 by the royal college, and as of 2017 the vast majority of ect clinics in england, wales, northern ireland and the republic of ireland have signed up. the mental health act 2007 allows people to be treated against their will. this law has extra protections regarding ect. a patient capable of making the decision can decline the treatment, and in that case treatment cannot be given unless it will save that patient's life or is immediately necessary to prevent deterioration of the patient's condition. a patient may not be capable of making the decision (they "lack capacity"), and in that situation ect can be given if it is appropriate and also if there are no advance directives that prevent the use of ect. china ect was introduced in china in the early 1950s and while it was originally practiced without anesthesia, as of 2012 almost all procedures were conducted with it. as of 2012, there are approximately 400 ect machines in china, and 150,000 ect treatments are performed each year. chinese national practice guidelines recommend ect for the treatment of schizophrenia, depressive disorders, and bipolar disorder and in the chinese literature, ect is an effective treatment for schizophrenia and mood disorders. although the chinese government stopped classifying homosexuality as an illness in 2001, electroconvulsive therapy is still used by some establishments as a form of "conversion therapy". alleged internet addiction (or general unruliness) in adolescents is also known to have been treated with ect, sometimes without anestheia, most notably by yang yongxin. the practice was banned in 2009 after news on yang broke out. society and culture controversy surveys of public opinion, the testimony of former patients, legal restrictions on the use of ect and disputes as to the efficacy, ethics and adverse effects of ect within the psychiatric and wider medical community indicate that the use of ect remains controversial. this is reflected in the january 2011 vote by the fda's neurological devices advisory panel to recommend that fda maintain ect devices in the class iii device category for high risk devices, except for patients with catatonia, major depressive disorder, and bipolar disorder. this may result in the manufacturers of such devices having to do controlled trials on their safety and efficacy for the first time. in justifying their position, panelists referred to the memory loss associated with ect and the lack of long-term data. informed consent the world health organization (2005) advises that ect should be used only with the informed consent of the patient (or their guardian if their incapacity to consent has been established). in the us, this doctrine places a legal obligation on a doctor to make a patient aware of the reason for treatment, the risks and benefits of a proposed treatment, the risks and benefits of alternative treatment, and the risks and benefits of receiving no treatment. the patient is then given the opportunity to accept or reject the treatment. the form states how many treatments are recommended and also makes the patient aware that consent may be revoked and treatment discontinued at any time during a course of ect. the us surgeon general's report on mental health states that patients should be warned that the benefits of ect are short-lived without active continuation treatment in the form of drugs or further ect, and that there may be some risk of permanent, severe memory loss after ect. the report advises psychiatrists to involve patients in discussion, possibly with the aid of leaflets or videos, both before and during a course of ect. according to the us surgeon general, involuntary treatment is uncommon in the us and is typically used only in cases of great extremity, and only when all other treatment options have been exhausted. the use of ect is believed to be a potentially life-saving treatment. in one of the few jurisdictions where recent statistics on ect usage are available, a national audit of ect by the scottish ect accreditation network indicated that 77% of patients who received the treatment in 2008 were capable of giving informed consent. in the uk, in order for consent to be valid it requires an explanation in "broad terms" of the nature of the procedure and its likely effects. one review from 2005 found that only about half of patients felt they were given sufficient information about ect and its adverse effects and another survey found that about fifty percent of psychiatrists and nurses agreed with them. a 2005 study published in the british journal of psychiatry described patients' perspectives on the adequacy of informed consent before ect. the study found that "about half (45–55%) of patients reported they were given an adequate explanation of ect, implying a similar percentage felt they were not." the authors also stated: approximately a third did not feel they had freely consented to ect even when they had signed a consent form. the proportion who feel they did not freely choose the treatment has actually increased over time. the same themes arise whether the patient had received treatment a year ago or 30 years ago. neither current nor proposed safeguards for patients are sufficient to ensure informed consent with respect to ect, at least in england and wales. involuntary ect procedures for involuntary ect vary from country to country depending on local mental health laws. united states in most states in the us, a judicial order following a formal hearing is needed before a patient can be forced to undergo involuntary ect. however, ect can also be involuntarily administered in situations with less immediate danger. suicidal intent is a common justification for its involuntary use, especially when other treatments are ineffective. united kingdom until 2007 in england and wales, the mental health act 1983 allowed the use of ect on detained patients whether or not they had capacity to consent to it. however, following amendments which took effect in 2007, ect may not generally be given to a patient who has capacity and refuses it, irrespective of his or her detention under the act. in fact, even if a patient is deemed to lack capacity, if they made a valid advance decision refusing ect then they should not be given it; and even if they do not have an advance decision, the psychiatrist must obtain an independent second opinion (which is also the case if the patient is under age of consent). however, there is an exception regardless of consent and capacity; under section 62 of the act, if the treating psychiatrist says the need for treatment is urgent they may start a course of ect without authorization. from 2003 to 2005, about 2,000 people a year in england and wales were treated without their consent under the mental health act. concerns have been raised by the official regulator that psychiatrists are too readily assuming that patients have the capacity to consent to their treatments, and that there is a worrying lack of independent advocacy. in scotland, the mental health (care and treatment) (scotland) act 2003 also gives patients with capacity the right to refuse ect. regulation in the us, ect devices came into existence prior to medical devices being regulated by the food and drug administration. in 1976, the medical device regulation act required the fda to retrospectively review already existing devices, classify them, and determine whether clinical trials were needed to prove efficacy and safety. the fda initially classified the devices used to administer ect as class iii medical devices. in 2014, the american psychiatric association petitioned the fda to reclassify ect devices from class iii (high-risk) to class ii (medium-risk), which would significantly improve access to an effective and potentially lifesaving treatment. a similar reclassification proposal in 2010 met