Ayahuasca and Dimethyltryptamine Adverse Events and Toxicity Analysis: A Systematic Thematic Review

The objective of this paper is to conduct a systematic thematic review of adverse events, safety, and toxicity of traditional ayahuasca plant preparations and its main psychoactive alkaloids (dimethyltryptamine [DMT], harmine, harmaline, and tetrahydroharmine), including discussing clinical considerations (within clinical trials or approved settings). A systematic literature search of preclinical, clinical, epidemiological, and pharmacovigilance data (as well as pertinent reviews and case studies) was conducted for articles using the electronic databases of PubMed and Web of Science (to 6 July 2023) and PsycINFO, ClinicalTrials.gov, and Embase (to 21 September 2022) and included articles in English in peer-reviewed journals. Additionally, reference lists were searched. Due to the breadth of the area covered, we presented the relevant data in a thematic format. Our searches revealed 78 relevant articles. Data showed that ayahuasca or DMT is generally safe; however, some adverse human events have been reported. Animal models using higher doses of ayahuasca have shown abortifacient and teratogenic effects. Isolated harmala alkaloid studies have also revealed evidence of potential toxicity at higher doses, which may increase with co-administration with certain medications. Harmaline revealed the most issues in preclinical models. Nevertheless, animal models involving higher-dose synthetic isolates may not necessarily be able to be extrapolated to human use of therapeutic doses of plant-based extracts. Serious adverse effects are rarely reported within healthy populations, indicating an acceptable safety profile for the traditional use of ayahuasca and DMT in controlled settings. Further randomized, controlled trials with judicious blinding, larger samples, and longer duration are needed.

Potential therapeutic effects of an ayahuasca-inspired N,N-DMT and harmine formulation: a controlled trial in healthy subjects

Background

There is growing scientific evidence for the therapeutic benefits of the Amazonian plant-based psychedelic "ayahuasca" for neuropsychiatric disorders such as depression and anxiety. However, there are certain challenges when incorporating botanical ayahuasca into biomedical research and clinical therapy environments. Formulations inspired by ayahuasca, which contain specific and standardized active components, are a potential remedy.

Methods

We investigated subjective acute and persisting effects of a novel formulation containing the reversible monoamine oxidase inhibitor harmine (orodispersible tablet containing 100 mg MAO-I) and N,N-dimethyltryptamine (incremental intranasal dosing of up to 100 mg DMT), compared with two other conditions, namely harmine alone and placebo, in a crossover RCT in 31 healthy male subjects.

Results

DMT + harmine, but not harmine alone, induced a psychedelic experience assessed with the 5D-ASC rating scale [global score: F(2,60) = 80.21, p < 0.001] and acute experience sampling items over time, characterized by psychological insights [PIQ, F(2,58.5) = 28.514, p < 0.001], emotional breakthroughs [EBI, F(2,60) = 26.509, p < 0.001], and low scores on the challenging experience questionnaire [CEQ, F(2,60) = 12.84, p < 0.001]. Participants attributed personal and spiritual significance to the experience (GSR) with mainly positive persisting effects (PEQ) at 1- and 4-months follow-up. Acute drug effects correlated positively with persisting effects. We found no changes in trait measures of personality, psychological flexibility, or general well-being, and no increases in psychopathology (SCL-90-R) were reported.

Discussion and Conclusion

Our results suggest that the experience induced by the standardized DMT + harmine formulation induces a phenomenologically rich psychedelic experience, demonstrates good psychological safety and tolerability, is well tolerated, and induces beneficial psychological processes that could possibly support psychotherapy. Further studies are required to investigate the psychotherapeutic potential in patients.

Ayahuasca: A review of historical, pharmacological, and therapeutic aspects

Ayahuasca is a psychedelic plant brew originating from the Amazon rainforest. It is formed from two basic components, the Banisteriopsis caapi vine and a plant containing the potent psychedelic dimethyltryptamine (DMT), usually Psychotria viridis. Here we review the history of ayahuasca and describe recent work on its pharmacology, phenomenological responses, and clinical applications. There has been a significant increase in interest in ayahuasca since the turn of the millennium. Anecdotal evidence varies significantly, ranging from evangelical accounts to horror stories involving physical and psychological harm. The effects of the brew on personality and mental health outcomes are discussed in this review. Furthermore, phenomenological analyses of the ayahuasca experience are explored. Ayahuasca is a promising psychedelic agent that warrants greater empirical attention regarding its basic neurochemical mechanisms of action and potential therapeutic application.

A quantitative textual analysis of the subjective effects of ayahuasca in naïve users with and without depression

Ayahuasca is a brew with psychoactive properties that has been used as an entheogen for centuries, with more recent studies suggesting it is a promising treatment for some clinical disorders. Although there is an emerging scientific literature on its effects, to the best of our knowledge no study has explored the self-reported experiences of first-time ayahuasca users with quantitative textual analysis tools. Accordingly, the current study aimed to analyze the subjective experience of naive individuals with depression and healthy controls after consuming ayahuasca. For this purpose, responses from a subsample of participants from a previous clinical trial to open-ended questions regarding their experience with ayahuasca underwent textual analysis. Data from nine patients with treatment-resistant depression and 20 healthy individuals were included, and quantitative textual analysis was performed using IRaMuTeQ 0.7 alpha 2 and R 3.1.2. The analysis identified five clusters: alterations in the state of consciousness, cognitive changes, somatic alterations, auditory experiences, and visual perceptual content. Additionally, findings suggest specific features of the experience of people with depression with ayahuasca, such as increased aversive bodily reactions. The results are consistent with previous findings indicating central axes of the psychedelic experience, and may inform therapeutic approaches using ayahuasca.

This is your brain on death: a comparative analysis of a near-death experience and subsequent 5-Methoxy-DMT experience

Introduction

Much research has focused on the modeling of the near-death experience (NDE) by classical and atypical psychedelics; however, to date, no study has reported on the relationship between the NDE and the experience induced by the highly potent, endogenous psychedelic drug 5-Methoxy-DMT (5MeO-DMT). This article presents a case study of an individual who is popularly documented to have had a profound near-death experience while in a coma caused by bacterial meningoencephalitis. Additionally, the individual also subsequently underwent an experience with 5MeO-DMT.

Methods

A semi-structured interview was conducted with the subject concerning his experiences with both the NDE and 5MeO-DMT. A basic thematic analysis was performed on both the original text describing the NDE as well as the interview itself, which mainly focused on the subject's experience with 5MeO-DMT. This analysis was organized to identify both the similar and different emergent themes between the two states, with a particular emphasis on the subject's perceptions of the similarities and differences between the experiences.

Results

There is a very high level of comparability between the original NDE and psychedelic experiences in general, including shared characteristics such as entering other worlds, meeting menacing or benevolent entities, experiencing synesthesia, perinatal regression, and lucid dreamlike properties. Much comparability was also identified with the 5MeO-DMT experience, in particular the major mystical experiential domains, such as ego dissolution, but especially transcendence of time and space. However, there were also a few unique themes (life review, the deceased, and the threshold) that emerged in the NDE that were not present in the 5MeO-DMT experience or other psychedelic experience studies, suggesting that these themes may be more unique to the NDE.

Discussion

Despite such similarities, the participant asserted that his NDE and psychedelic experiences were not similar enough to be attributed to endogenous psychedelics. In this study, we discussed several mechanisms that could potentially account for the NDE, including lucid dreams and perinatal regression. However, the study also explored the possibility that the unique etiology of the participant's NDE, bacterial meningoencephalitis affecting the neocortex, may have triggered similar downstream neural activity as that initiated by psychedelic agents through pyramidal neuronal activation. This hypothesis is presented with appropriate caveats and acknowledged as speculative.

Prevalence and therapeutic impact of adverse life event reexperiencing under ceremonial ayahuasca

The present study examined the safety and efficacy of the ceremonial use of ayahuasca in relation to reports of heightened life event reexperiencing under psychedelics. The study examined (1) the prevalence of specific types of adverse life event reexperiencing, (2) characteristics predictive of reexperiencing, (3) the psychological character of reexperiencing, and (4) the impact of reexperiencing on mental health. Participants were recruited from three ayahuasca healing and spiritual centers in South and Central America (N = 33 military veterans, 306 non-veterans) using self-report data at three timepoints (Pre-retreat, Post-retreat, 3-months post-retreat). Reexperiencing adverse life events under ayahuasca was common, with women showing particularly high probability of reexperiencing sexual assault, veterans reexperiencing combat-related trauma, and individuals with a self-reported lifetime diagnosis of post-traumatic stress disorder exhibiting a substantively higher prevalence of reexperiencing. Reexperiencing was associated with states of cognitive reappraisal, psychological flexibility, and discomfort during ceremonies, and participants who reexperienced adverse life events exhibited greater reductions in trait neuroticism following their ceremonies. Clinical implications of these results for the application of psychedelics to mood and stress disorders are discussed.

Ayahuasca Ritual, Personality and Sociality: Observational Research Conducted in a Substance Use Disorder Rehabilitation Center in Uruguay

The current article presents a mixed qualitative-quantitative observational study of the effect of ayahuasca ritual on subjective experiences and personality traits on participants of a center specialized in the treatment of substance use disorder in Uruguay. When comparing the psychological traits of ayahuasca participants to a control group, quantitative results using the Zuckerman-Kuhlman-Aluja Personality Questionnaire showed statistically significant higher scores in Impulsive Sensation Seeking, Boredom Susceptibility, and Social Warmth scales. Qualitative analysis of ayahuasca experiences resulted in five main categories: emotional experiences (including social emotions such as love and empathy), corporal experiences, spiritual/transcendental experiences, personal experiences, and visions. Last, qualitative descriptions provide support for the importance of social interactions in the phenomenological manifestations of the psychedelic experience. Both quantitative and qualitative results suggest that the combination of social interactions and the pharmacological action of ayahuasca could facilitate the manifestation of social emotions during the ritual, and may contribute to the long-term increase of empathic and social aspects of personality.

Examining the Therapeutic Effect of Ceremonial Ayahuasca on Narcissistic Personality and Antagonistic Externalizing in Adults

Changes in narcissistic traits (e.g., entitlement) following the ceremonial use of ayahuasca were examined across three timepoints (baseline, postretreat, 3-month follow-up) in a sample of 314 adults using self- and informant-report (N = 110) measures. Following ceremonial use of ayahuasca, self-reported changes in narcissism were observed (i.e., decreases in Narcissistic Personality Inventory [NPI] Entitlement-Exploitativeness, increases in NPI Leadership Authority, decreases in a proxy measure of narcissistic personality disorder [NPD]). However, effect size changes were small, results were somewhat mixed across convergent measures, and no significant changes were observed by informants. The present study provides modest and qualified support for adaptive change in narcissistic antagonism up to 3 months following ceremony experiences, suggesting some potential for treatment efficacy. However, meaningful changes in narcissism were not observed. More research would be needed to adequately evaluate the relevance of psychedelic-assisted therapy for narcissistic traits, particularly studies examining individuals with higher antagonism and involving antagonism-focused therapeutic approaches.

The felt-presence experience: from cognition to the clinic

The felt presence experience is the basic feeling that someone else is present in the immediate environment, without clear sensory evidence. Ranging from benevolent to distressing, personified to ambiguous, felt presence has been observed in neurological case studies and within psychosis and paranoia, associated with sleep paralysis and anxiety, and recorded within endurance sports and spiritualist communities. In this Review, we summarise the philosophical, phenomenological, clinical, and non-clinical correlates of felt presence, as well as current approaches that use psychometric, cognitive, and neurophysiological methods. We present current mechanistic explanations for felt presence, suggest a unifying cognitive framework for the phenomenon, and discuss outstanding questions for the field. Felt presence offers a sublime opportunity to understand the cognitive neuroscience of own-body awareness and social agency detection, as an intuitive, but poorly understood, experience in health and disorder.

Restructuring insight: An integrative review of insight in problem-solving, meditation, psychotherapy, delusions and psychedelics

Occasionally, a solution or idea arrives as a sudden understanding - an insight. Insight has been considered an "extra" ingredient of creative thinking and problem-solving. Here we propose that insight is central in seemingly distinct areas of research. Drawing on literature from a variety of fields, we show that besides being commonly studied in problem-solving literature, insight is also a core component in psychotherapy and meditation, a key process underlying the emergence of delusions in schizophrenia, and a factor in the therapeutic effects of psychedelics. In each case, we discuss the event of insight and its prerequisites and consequences. We review evidence for the commonalities and differences between the fields and discuss their relevance for capturing the essence of the insight phenomenon. The goal of this integrative review is to bridge the gap between the different views and inspire interdisciplinary research efforts for understanding this central process of human cognition.

Psychotherapeutic and neurobiological processes associated with ayahuasca: A proposed model and implications for therapeutic use

Ayahuasca is a psychoactive Amazonian plant brew. It is usually made from the Banisteriopsis caapi vine (Spruce ex Griseb. Morton, Malpighiaceae), which contains three primary harmala alkaloids, along with the leaves of Psychotria viridis (Ruiz et Pavon, Rubiaceae) in which the potent psychedelic dimethyltryptamine (DMT) is found. DMT-harmaloid concoctions have gained popularity in recent years, due to growing anecdotal and scientific reports of therapeutic benefits associated with their consumption. Ayahuasca is now ingested in a variety of different settings across the globe, from traditional ethnobotanical to so called "neo-shamanic" ceremonies. Furthermore, related preparations involving alternative sources of DMT and harmala alkaloids are becoming increasingly common as knowledge of ayahuasca continues to spread internationally. This article reviews the existing literature and draws on original qualitative data from a large cross-sectional study of ayahuasca drinkers, to propose a model of psychotherapeutic processes associated with the consumption of ayahuasca. We assert that it is these processes, facilitated by a range of neurobiological effects, that lead to beneficial mental health and wellbeing outcomes. Our proposed model identifies five key psychotherapeutic processes or effects inherent to the ayahuasca experience; somatic effects; introspection and emotional processing; increased Self-connection; increased spiritual connection, and finally the gaining of insights and new perspectives. We note some important differences in these processes compared with other classic psychedelics as well as the implications of the model for the therapeutic use of ayahuasca. Improved understanding of the psychotherapeutic processes involved with the ayahuasca experience will better equip practitioners to work with this potentially transformative concoction and enable the optimization of therapeutic treatment models for potential clinical use.

Ayahuasca's therapeutic potential: What we know - and what not

The therapeutic potential of the psychedelic brew ayahuasca has been investigated in preclinical and clinical studies. Currently, the most consistent evidence refers to depression. However, various studies suggest that ayahuasca may comprise therapeutic benefits in other health conditions. This narrative review provides a comprehensive, up-to-date overview of ayahuasca's therapeutic effects in diverse clinical conditions in human (clinical, cross-sectional, observational, and qualitative) and preclinical (animal and in vitro) studies. In addition to summarizing and discussing the most commonly studied conditions, such as depression, anxiety, and substance use disorders (SUD), we also examine less frequently studied psychiatric, neurological, and physical conditions. Moreover, we discuss evidence from epidemiological studies on the impact of regular, long-term ayahuasca use on health and psychosocial outcomes. Overall, evidence for depression and SUD is more consistent, with numerous and diverse studies. However, a growing body of evidence suggests that other conditions equally relevant to public health might be promising targets for ayahuasca's therapeutic effects. This includes preliminary studies indicating potential for grief, eating disorders, posttraumatic stress disorder, personality disorders, Parkinson's and Alzheimer's disease, and severe physical illnesses (e.g., cancer, chronic conditions). Moreover, preliminary evidence in long-term ayahuasca users does not suggest detrimental effects but possible benefits for individual and collective health. In light of the emerging evidence of psychedelic drugs as therapeutic agents, it is essential to further investigate in rigorous designs the therapeutic potential of ayahuasca in conditions other than depression.

Psychological effects and subjective experiences of ayahuasca rituals in participants of two neoshamanic centers of Uruguay

Background

Ayahuasca's psychological and subjective effects were compared in rituals of two neoshamanic groups in Uruguay.

Aims

Compare, describe and analyze psychological effects and subjective experiences of ayahuasca ceremonies in two different groups: a psychospiritual holistic center, and a center specialized in substance use disorder's treatment.

Methods

A mixed qualitative-quantitative study was conducted, using the Hallucinogen Rating Scale for measuring psychological effects, and in-depth interviews for the description of ayahuasca subjective experiences. Data from both techniques were compared, analyzing convergences and differences.

Results

When comparing the two neoshamanic groups, significant differences with a medium-size effect were found in the psychological variables Affect (r = 0.47), Cognition (r = 0.36) and Perception (r = 0.36). The qualitative descriptions of ayahuasca experiences in the group with higher scores in those variables showed more frequent and complex experiences of emotional, cognitive, and perceptive content. Dissimilar results were found when comparing Intensity and Somaesthetic domains, with no significant results in the quantitative part, while in the qualitative part intensity was reported as “soft” in one group, and corporal experiences (e.g., purging effects) were especially manifested.

Conclusions

Stronger subjective experiences and higher psychological effects may be related to differences in the dosage and the setting of the centers. Emotional, cognitive, and perceptive psychological effects of ayahuasca rituals measured by the Hallucinogen Rating Scale, seem to be associated with more frequent and complex subjective experiences in the mentioned domains. Qualitative group differences in corporal alterations and the overall intensity of the experience differed from non-significant results of the quantitative part of the study.

An Encounter With the Other: A Thematic and Content Analysis of DMT Experiences From a Naturalistic Field Study

Introduction: N,N-dimethyltryptamine (DMT) is an endogenous serotonergic psychedelic capable of producing radical shifts in conscious experience. Increasing trends in its use, as well as new trials administering DMT to patients, indicate the growing importance of a thorough elucidation of the qualitative content, over and above structure, which the drug occasions. This is particularly in light of the hyper-real, otherworldly, and often ontologically challenging yet potentially transformative, nature of the experience, not least encounters with apparently non-self social agents. Laboratory studies have been limited by clinical setting and lacking qualitative analyses of experiential content, while online surveys' limitations lie in retrospective design, uncontrolled use, and both of which not guaranteeing 'breakthrough' experiences, i.e., producing very strong psychoactive effects. Methods: We report on the first naturalistic field study of DMT use including its qualitative analysis. Screened, healthy, anonymised and experienced DMT users were observed during their non-clinical use of the drug at home (40-75 mg inhaled). In-depth semi-structured interviews (inspired by the micro-phenomenological technique) were employed immediately after their experience. This paper reports on the thematic analysis of one major domain of the breakthrough experiences elicited, the 'other'. Thirty-six post-DMT experience interviews with mostly Caucasian (83%) males (eight female) of average 37 years were predominantly inductively coded. Results: Invariably, profound and highly intense experiences occurred. The first overarching category comprised the encounter with other 'beings' (94% of reports), encompassing super-ordinate themes including the entities' role, appearance, demeanour, communication and interaction; while the second overarching category comprised experiences of emerging into other 'worlds' (100% of reports), encompassing super-ordinate themes of the scene, the contents and quality of the immersive spaces. Many further mid-level themes and subthemes also illuminate the rich content of the DMT experience. Discussion: The present study provides a systematic and in-depth analysis of the nuanced content of the otherworldly encounter within the breakthrough DMT experience, as well as elaborating on the resonances both with previous DMT studies focusing on entity encounters and other types of extraordinary experiences entailing such encounters. These include the alien abduction, folkloric, shamanic and near-death experience. Putative neural mechanisms of these features of the DMT experience and its promise as a psychotherapeutic agent are discussed in light of such findings.

Ceremonial Ayahuasca in Amazonian Retreats-Mental Health and Epigenetic Outcomes From a Six-Month Naturalistic Study

Ayahuasca is a natural psychoactive brew, used in traditional ceremonies in the Amazon basin. Recent research has indicated that ayahuasca is pharmacologically safe and its use may be positively associated with improvements in psychiatric symptoms. The mechanistic effects of ayahuasca are yet to be fully established. In this prospective naturalistic study, 63 self-selected participants took part in ayahuasca ceremonies at a retreat centre in the Peruvian Amazon. Participants undertook the Beck Depression Inventory (BDI-II), State-Trait Anxiety Inventory (STAI), Self-compassion Scale (SCS), Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM), as well as secondary measures, pre- and post-retreat and at 6-months. Participants also provided saliva samples for pre/post epigenetic analysis. Overall, a statistically significant decrease in BDI-II (13.9 vs. 6.1, p < 0.001), STAI (44.4 vs. 34.3 p < 0.001) scores, and CORE-OM scores were observed (37.3 vs. 22.3 p < 0.001) at post-retreat, as well as a concurrent increase in SCS (3.1 vs. 3.6, p < 0.001). Psychometric improvements were sustained, and on some measures values further decreased at 6-month follow-up, suggesting a potential for lasting therapeutic effects. Changes in memory valence were linked to the observed psychometric improvements. Epigenetic findings were equivocal, but indicated that further research in candidate genes, such as sigma non-opioid intracellular receptor 1 (SIGMAR1), is warranted. This data adds to the literature supporting ayahuasca's possible positive impact on mental health when conducted in a ceremonial context. Further investigation into clinical samples, as well as greater analyses into the mechanistic action of ayahuasca is advised.

The ritual use of ayahuasca during treatment of severe physical illnesses: a qualitative study

Diseases that threaten life raise existential questions that can be a source of psychological distress. Studies with psychedelics demonstrate therapeutic effects for anxiety and depression associated with life-threatening illnesses. Ayahuasca has been proposed as a possible therapeutic agent in the treatment of psychiatric disorders. Preliminary studies suggest that ayahuasca could promote therapeutic effects for people with physical illnesses. The aim of this study was to explore how the ritual use of ayahuasca during the treatment of severe physical illnesses (SPI) may influence the way people understand and relate to their illness, using qualitative methods to assess the participants' perspectives. Participants who consumed ayahuasca ritualistically during the period of treatment for SPI were purposely chosen. Data were obtained through semi-structured interviews. A thematic analysis was performed with 14 individuals. The ritual experience with ayahuasca acted on the participants' illness understanding through multiple psychological mechanisms, including introspection, self-analysis, emotional processing and catharsis, recall of autobiographical memories subjectively related to illness origin, illness resignification, and perspective changes. This study suggests that the experience with ayahuasca may facilitate illness acceptance through an influence on the meanings of the illness, life, and death. These changes may favor a more balanced relationship with illness and treatment.

Modulatory effects of ayahuasca on personality structure in a traditional framework

Ayahuasca is a psychoactive plant brew containing dimethyltryptamine (DMT) and monoamine oxidase inhibitors (MAOIs). It originates from the Amazon basin, where it is used primarily for ceremonial purposes. Ayahuasca tourists are now entering certain communities seeking alternative physical or psychological healing, as well as spiritual growth.

RATIONALE

Recent evidence has shown that the similar acting psychedelic compound, psilocybin, facilitated long-term increases in trait openness following a single administration.

OBJECTIVES

This paper assesses the impact of ayahuasca on personality in a traditional framework catering for ayahuasca tourists.

METHOD

Within a mixed design, we examined the effect of ayahuasca on participants' personality (measured by the NEO Personality Inventory 3 questionnaire) across time (pre- to post-ayahuasca administration, and 6-month follow-up), relative to a comparison group (who did not ingest ayahuasca).

RESULTS

The results demonstrated significant increases in agreeableness pre- and post-ayahuasca administration and significant reductions in neuroticism in 24 participants, relative to the comparison group. Both of these changes were sustained at 6-month follow-up, and trait level increases were also observed in openness at this stage. Additionally, greater perceived mystical experience (measured using the Mystical Experience Questionnaire 30) was associated with increased reductions in neuroticism.

CONCLUSIONS

These findings, which indicate a positive mediating effect of ayahuasca on personality, support the growing literature suggesting potential therapeutic avenues for serotonergic psychedelics.

Purging and the body in the therapeutic use of ayahuasca

Ayahuasca is a psychoactive plant mixture used in ceremonial contexts throughout Western Amazonia. Its use has expanded globally in recent decades and become popular among westerners who travel to the Peruvian Amazon in increasing numbers to experience its reportedly healing effects. Through a review of relevant literature on Amazonian shamanism, combined with the authors' ethnographic data from shamanic tourism contexts of the Peruvian Amazon and neo-shamanic networks in Australia (collected between 2003 and 2015 - with a total of 227 people interviewed or surveyed, including healers and participants), we demonstrate that purging has been integral to the therapeutic use of ayahuasca across and beyond Amazonia. Therapeutic approaches to ayahuasca point to combined modulations of the gut and the mind, and the bodily and the social, that are expressed through discourse about healing and the body. Relating ethnographic evidence to recent scientific studies that connect the gut to emotional health, we do not approach the gut as merely biological ground on which cultural meanings are imposed, but rather as simultaneously physical and cultural. Based upon our analysis, we argue that ayahuasca purging should not be dismissed as a drug side effect or irrational belief but reconsidered for its potential therapeutic effects.