The use of electroconvulsive therapy (ECT) in U.S. state hospitals has markedly decreased in the past 20 years. During this time ECT technique has reached a high level of sophistication. We examine whether ECT still has a place and can be effectively used in a modern state hospital. We conclude that approximately 1% of state hospital patients are candidates for ECT and that patients with major depression, mania, schizoaffective disorder, and schizophrenia may benefit from such treatment. The relative youth and good physical health of state hospital patients referred for ECT reduces the risk of the procedure in this setting. Most of our patients were on civil commitment but retained the capacity to consent to treatment. We discuss the use of inpatient continuation ECT and the treatment of protracted psychotic excitement as issues relevant to state hospitals.