OBJECTIVE Little epidemiologic research has examined the practice of electroconvulsive therapy (ECT). We investigated sociodemographic and clinical characteristics, service use, and psychotropic medication prescription patterns associated with ECT use at a Veterans Health Administration Medical Center. METHODS Among veterans receiving specialty mental health services, we compared those who received ECT with those who did not using bivariate χ and t tests and multivariate logistic regression. RESULTS In fiscal year 2012, 11,117 veterans received specialty mental health services, of whom 50 received ECT (0.45%) in FY2012 or FY2013. Those who received ECT were more likely to be diagnosed with major depressive or bipolar disorders and had substantially higher levels of mental health service usage (Cohen d > 0.75) and psychotropic prescription fills, including antidepressants (Cohen d = 2.66), antipsychotics (Cohen d = 2.15), lithium (Cohen d = 1.34), mood stabilizers (Cohen d = 1.30), and anxiolytic/sedative/hypnotics (Cohen d = 1.34). CONCLUSIONS Our findings suggest that ECT is used as a treatment of last resort, although available evidence and guidelines recommend wider use.