The use of ECT in California was examined from 1984 to 1994 and compared with a previous study examining use from 1977 to 1983. Data were collected from legally required reports submitted to the state for all ECT performed. A total of 28,437 patients (mean = 2585.18 per year) received a total of 160,847 treatments with a mean rate of 0.90 patients/10,000 population. The rate in 1984 (1.15) was similar to the mean rate for 1977–1983 (1.12). The rate dropped in 1986 (0.92) and again in 1991 (0.74). There were 821 patients (2.89% of total) judged to be incapable of giving informed consent who received ECT after a court review. This is similar to the rate of 3% for 1977 to 1983. The number of counties where ECT was available increased from 15 in 1983 to 19 in 1991 and returned to 15 in 1994. The number of facilities providing ECT increased from 62 in 1983 to 83 in 1990 and decreased to 69 in 1994. White patients comprised 91.5% of ECT recipients. Three deaths were reported for a rate of 0.19 deaths/10,000 treatments. Despite its safety and efficacy, the availability of ECT in California continues to remain limited geographically and socioeconomically. The rate of its use has declined. Access to ECT is most limited for public patients. While some of the decline may be related to the introduction of new antidepressants and the rapid expansion of managed care, complex legal regulation bears much of the responsibility.