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The exact mechanism for how it improves depression symptoms is still debated and not really understood.
As for how it's done, it's usually done in a hospital. I go to the PACU (Post Anesthesia Care Unit), get in a hospital gown, hooked up to an IV and all the monitors, then wait. Then the ECT team and Anesthesia team come in. I get hooked up with monitors for the ECT machine. Then they do a time-out to double-check everything. After that, things move pretty quickly.
First they give me oxygen through a mask. Then they give the anesthesia through the IV, and I go unconscious. Once they make sure I'm fully out, they give the paralytic. At that point, the nurse anesthetist starts breathing for me. Once the paralytic is fully in effect, they deliver a brief shock to induce the seizure. The doctors monitor my brain waves to make sure I actually have the seizure and it lasts long enough. They also keep an eye on my vital signs to make sure I'm OK. Once the seizure is over and the paralytic wears off, the PACU nurses take over and I wake up. I timed it last time and it took about 45 minutes from Time-Out to me waking up. After I wake up, the nurses check my vitals to make sure I'm OK. Then I get dressed and I get to go home.