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Electroconvulsive therapy (ECT) is an established intervention for severe or treatment-resistant psychiatric illnesses, including depression, schizophrenia, mania and catatonia. Despite its efficacy, concerns over its risks have contributed to ongoing stigma and hesitancy regarding its use. Traditional clinical trials have demonstrated the superiority of ECT in symptom reduction compared with other treatments, yet are impractical for assessing rare or long-term outcomes. Observational studies using administrative health data can assess rare or long-term outcomes, but are limited by confounding/bias. This review synthesises evidence from studies utilising administrative health data and modern statistical methods to address clinically relevant questions about ECT's association with (a) dementia, (b) major adverse cardiovascular/cerebrovascular events, (c) suicide deaths and (d) all-cause mortality. Most studies indicate that, after adjusting for confounding, ECT does not increase the risk of dementia or major adverse cardiovascular/cerebrovascular events. Furthermore, ECT is likely associated with a substantial reduction in suicide mortality and all-cause mortality. Although observational studies cannot fully eliminate unmeasured confounding, the consistency of the findings from diverse investigators and congruence with clinical trials and neuroimaging studies lends support to their validity. These modern observational studies have yielded results that reinforce ECT's safety and efficacy supporting its position as a life-saving treatment.