Can one of the best treatments for depression move past its old reputation?

On a sunny November afternoon, Gerard Robinson set out from his Johnson Ferry Road apartment and walked his terrier. The simple act was a revolution for him.

Robinson’s walk would have been unthinkable just last year, as he sat in his apartment suffering from severe depression. The disease was defying other treatments Robinson had diligently tried, and he was at his wits’ end. But in the fall of 2023, he sought and received a treatment that changed all that.

The treatment is electroconvulsive therapy, also known as ECT. In popular culture it has another name: shock therapy.

“For depression, I will say that it is the most effective treatment that we have in psychiatry,” said one member of his care team, Dr. Brandon Kitay of Emory Decatur Hospital’s neuromodulation clinic.

It’s also one of the least used. Emory gives the treatment to just 250 or so patients a year, and in that it’s a leader. Most hospitals don’t offer it. “It is grossly underutilized,” Kitay said.

How one of the most effective treatments there is for the nation’s most common disability – depression – could be so rarely used is a matter of deep frustration to Kitay and his colleagues. The biggest reason for its unpopularity, according to Dr. Robert Ostroff of Yale University, is the enduring stigma attached to it. In the Jack Nicholson movie “One Flew Over the Cuckoo’s Nest,” it was depicted as an abusive treatment that leaves patients catatonic. This bears no resemblance to current treatments, experts said.

“‘One Flew Over the Cuckoo’s Nest’ did to ECT what ‘Jaws’ did to sharks,” said Kitay’s colleague, Dr. Patricio Riva Posse, who oversees the clinic’s ECT, quoting another colleague who also studies ECT.

Benefits and risks

Every treatment has risks, and ECT’s are as real as any other.

In deciding whether it’s safe and effective, researchers weigh the benefits against those risks. “The numbers are about what you would expect from like an outpatient colonoscopy treatment,” Kitay said, referencing another medical procedure where patients are sedated.

ECT is a course of several treatments in which doctors deliver electric currents in small pulses to the brain. In a treatment, clinicians place electrodes on the patient’s head. They give the patient general anesthesia, meaning they’re completely asleep and feel nothing during treatment. Patients might have a dozen treatments over a few weeks, usually outpatient procedures and each lasting 10 minutes or less.

Occasionally patients need follow-up maintenance treatments afterward.

Some of the most important advancements in recent years involve making changes to the electric pulses’ size and shape to cause fewer side effects while still being effective. Researchers are also finding different results depending on where the electrodes are placed. Smaller pulses and electrodes placed on just one side of the head can carry fewer risks and sometimes be just as effective.

Emory is among several international sites now cooperating in such a study, looking to see if slightly different electrode placement on the scalp works just as well and reduces the risks further.

If it weren’t for the anesthesia and a muscle relaxant also given to patients, the electric current would cause the patient’s body to convulse. That led to the name “electroconvulsive” therapy.

The core of the treatment is a seizure that interrupts the brain’s regular activity. Scientists are still sussing out whether it’s the electricity itself or the seizure that leads to the eventual improvements in mood.

Data varies, but it’s common for patients to experience some memory loss after ECT – but with modern methods, it’s not common for that to be long term. It’s crucial to understand the difference, say Kitay and Riva Posse.

After patients come out of their anesthesia, that day they may have recent memory gaps: For example, if the relative who drove them to the clinic discussed dinner plans, they may remember the drive and the driver, but not the dinner plans.

“That happens in 15%, 20% of the people during the ECT course,” Kitay said. “And then it resolves within a couple of weeks after that.”

Accurately tracking whether patients’ memory and cognition change after treatment is crucial for researchers now, Kitay said.

The numbers in research vary widely, but Kitay and Riva Posse said that those who show a long-term memory loss are fewer than 1%. There are research papers showing higher numbers, but often from studies done without objective measurements or many years ago before more modern improvements. One study from two decades ago, relying not on objective measurement but on patients’ own observations after the fact, found that between a quarter and half thought ECT had affected their memory.

The success rates of ECT for treatment-resistant depression run from 60% to higher than 80%, according to varying studies.

In contrast, the outcomes for depression without ECT treatment are stark. Research shows that people with depression are more than a third more likely to die of heart conditions. Risk of death by suicide is clear: About 30% of patients with treatment-resistant depression have had at least one suicide attempt.

And the need for effective treatments is vast. That has become clear, especially as awareness of mental health concerns has soared following the COVID-19 pandemic.

Research shows about 8% of Americans will have a major depressive episode in any given year.

Kitay added, “We do ECT in lawyers, doctors, engineers, journalists, university professors – you name it.”

The whole point is to get the patients out of their depression so they can regain the energy to think and to do things like go back to work, he said. He said none of his ECT patients has been less able to resume work and activities after treatment. “In fact, they are able to do that because they’re less depressed.”

Bad thoughts ‘evaporated’

As often happens, ECT helped Robinson’s thoughts of suicide vanish. That was almost immediate, he said.

Robinson had treatment-resistant depression and a diagnosis of bipolar disorder, he says. Before the ECT, Robinson, then 71, had intrusive thoughts about suicide. After one or two ECT sessions, he says, those thoughts “just evaporated.”

Overall depression symptoms take longer to fade after starting ECT. At first, Robinson thought the treatment hadn’t worked. Then as the weeks and months went by, the depression ebbed. He started walking his dog, Kerouac. Two screenplays he wrote and abandoned no longer seemed so daunting. He picked them up again and went to work on them.

Now Robinson said he’s getting more involved in Atlanta’s theater community. He goes to community events at the Plaza Theatre and at a restaurant nearby in Virginia Highlands. Between talks with a reporter about the benefits of ECT, he was apartment hunting, looking to move closer to that community. He accepted a Thanksgiving dinner party invitation from his brother’s friend.

“Yeah,” Robinson said. “It’s turning out to be a good year for me.”