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Personal Accounts: Life as Death: Hope Regained With ECT
Curtis E. Hartmann
Psychiatric Services 2002; doi: 10.1176/appi.ps.53.4.413
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Abraham Lincoln suffered horribly from depression. "I am now the most miserable man living," he wrote, in the throes of an episode. "If what I feel were distributed to the whole human family, there would be not one cheerful face on Earth. Whether I shall ever be better, I cannot tell; I awfully forebode I shall not. To remain as I am is impossible. I must die or be better, it appears to me."

It's a cold, raw, early spring morning, and I know, as Lincoln knew, that "to remain as I am is impossible." As Lincoln was, I am severely ill with depression. I am on my way to an appointment for shock treatment. I've done this over 100 times and yet remain tight with "first-time" anxiety. It's a clean, compassionate place, the Holyoke Hospital short-stay surgery unit in Holyoke, Massachusetts. Being a regular customer does ease some of my anxiety—the nurses and anesthesiologists greet me by name, and it makes me less nervous.

Electroconvulsive therapy (ECT) is done three mornings a week in the hospital's recovery room area. As in many hospitals, it is a routine procedure, and I know the routine: undress, get into surgical-patient hospital garb, remove my jewelry, pack my clothes into the plastic bag provided, stuff my wallet into the front of my topsiders (the process of securing "patient valuables" is a hassle).

The nurses say cheerily, "Good morning, Curtis," and despite my illness-in-hell, I am genuinely glad to see them. It is another reminder of how the chronic, debilitating, 32-year grip of my mental illness—bipolar disorder—has isolated me. It is not yet 7:00 a.m., and the medical prep of starting intravenous saline, taking my blood pressure, and confirming that I'm fasting have been done. I wait.

ECT, a treatment of last resort for severe, debilitating depression, is all that has ever worked for me. Invented in 1937 by an Italian neurologist after he had watched soon-to-be butchered pigs "anesthetized" by electricity, electroconvulsive therapy is simply that: the skull acts as a massive, generalized resister to a machine-generated electric pulse, and a full brain seizure is induced.

As I lie on the hospital gurney awaiting my turn, I silently thank ECT pioneer Harold Sackeim, Ph.D., a psychologist at Columbia University. Only months before, Dr. Sackeim had published a landmark study that proved that I can now get "the good without the bad." I can now receive a high-dose unilateral treatment, which has a therapeutic capacity equivalent to that of bilateral treatment. The downside of bilateral ECT has always been transient memory loss, confusion, and disorientation.

I am wheeled into the administration area, and monitors are attached to measure cardiac activity and intensity and duration of seizures. Dr. A, in his knowing, professional way, applies a conductive gel to my temples and adjusts the transmission-pulse headband. Preoxygenation of my brain is also routine in ECT, and the nurse adjusts the nasal cannula. The anesthesiologist, a warm, polite man, confirms the short-acting dose of anesthesia and muscle relaxant with Dr. A.

I am now ready but nowhere near ready. I remain scared.

While "on-deck" I had caught a glimpse of the anesthesiologist assisting the breathing of the previous ECT patient with a sterile Ambu bag. "Is respiratory arrest intrinsic to ECT," I ask myself, somewhat frightened, "or is the doctor simply helping the unconscious patient breathe?" I want to ask someone, but am afraid to. I do not ask.

Instead, I rely for comfort on the professional synchronicity of nurse-anesthesiologist-psychiatrist and their routine of administration. But primitive diabolical ECT images—tongue-biting, spine-fracturing, full-body seizures—assault my mind. "But that was all before general anesthesia, muscle relaxants, and scientific seizure monitoring," I reassure myself. "ECT has helped me for 25 years, and it will help this morning," I silently chant as the short-acting anesthetic is injected. "Breathe deeply," the anesthesiologist says soothingly, and before I can count to five, I feel a "drift," and I am unconscious. Relief does come.

I awaken about 20 minutes later, and although I am still groggy with anesthesia, much of the hellish depression is gone. "Depression," novelist William Styron wrote, "is a disease that mocks you and creates such intense, all-encompassing emotional anguish that it is beyond description." It is a disease that for me, literally steals me from myself—a disease that executes me and then forces me to stand and look down at my corpse. It is what the criminal lawyer in me calls a medical examiner's antithesis: life by strangulation. This disease of bipolar disorder (previously labeled manic-depression—more aptly in my opinion) has, by its "to the throat" depressions, ruled my life. For 32 years, since age 15, when I was unknowingly slipped LSD, I have battled the monster. It has had a hand in the ruination of three marriages; prevented the cultivation of a career despite college and law degrees, licensure as an attorney, and teacher certification; and kept me from working in the field that is my true love, journalism.

The disease has, because of unfortunate life circumstances created by incessant illness and because of doctors' recommendations (given the genetic passage of bipolar disorder from generation to generation), prevented me from having children I would dearly love. This, unquestionably, has been the cruelty hardest to bear: no children to love for a man who loves to love.

The depressions come without warning, striking in happy and sad times. Indeed, they seem, as the cliché goes, to have a mind of their own. Depression stayed away through the nine-month pressure cooker of preparation for the state bar exam and the two-day exam itself, but it hit while I was on feature assignment as a daily newspaper reporter. As I drove to a school to interview a Boston Celtics basketball star, my mood suddenly dropped as though from the top of an elevator shaft, and I could no longer write or work. The day before, I had felt fine, maybe even a bit hypomanic: I had been feeling like a perfectly tuned violin—a symphonic-synchronicity with mind and surroundings. Words for news stories flew effortlessly from my fingertips; the intricacies of a completed investigative news story made clear, precise sense.

But now, this horrible morning, the monster was back, and I had gone from violin to tuba. I could not carry on a conversation, could not sleep, had totally lost my appetite for food. Every action of self-preservation that the human species takes for granted simply died. Breakfast time was reduced to trying to comprehend the text on the Wheaties box. I mourned the loss of reading—the Sunday New York Times, novels, biography, history—which I loved before I became ill.

I had always known that my mind was intricately calibrated, and thus I always had the fond companionship of my thoughts and imagination. But, for reasons genetic, biochemical, neurochemical, and just reasons, I would forever pay for the overcalibration with this disease.

Personal hygiene, usually a simple habit, had become an Everest-like task. Most painful was the isolation of not belonging, of not having a place to go in the morning, of not having the kinship with fellow workers, of not speaking the occupational parlance—no newsrooms, no courthouses, no gossiping with and about fellow workers. All that nurturing stuff we need, and in so many ways, live for, was again stolen, gone, nonexistent. Again, I was sick. Again, I did not know if I could endure it.

As Styron remarked, depression, in its savagery, is not amenable to "a logical progression from the initial relief of symptoms to final cure." "There is no quick rescue," he said. There are no sores on the body to which one can point, no fever, no elevated blood count. There is not even a physical pain. There is, however, an emotional anguish whose depth and level of intensity taunt, harass, and forever scar. It is a cold, isolating hell, a hell that does not discriminate on the basis of class, race, ethnicity, or gender.

Although depression has been documented as a potentially lethal disease of epidemic proportions, taking a huge toll in lost productivity and costing billions to the world economy, for me it has always been more than a disease: it has taken my self-esteem, confidence, and pride, heaved them into a swamp of worthlessness, confusion, and, frequently, utter hopelessness.

The hopelessness is where so many languish, not knowing why, or how they got there, or how to get out. It is this hopelessness, kilned in isolation, and not necessarily the disease itself, that has nearly killed me. Indeed, the disease process is what made Lincoln observe, "To remain as I am is impossible." It is a process by which, of those who suffer it for more than a month, about 15 percent commit suicide. As the "All About Depression" page at the Web site of former Surgeon General C. Everett Koop notes, "Many of these patients seek medical help before their suicide, often within one month of their death."

Thus it is imperative, for me and for all depression survivors, to find and hold a basic hope—the hope that the depression will lift, that help can be found, that the bleakness is not forever. This is not easy. Hopelessness, the villain of all chronic disease—particularly insidious in depression, with its mastery of guerrilla tactics—grows exponentially as the disease progresses.

Hope, sometimes even blind hope, must somehow be grasped. It is best grasped not by a lone sentry of the night, but within true community—a place to go, to feel worthy, to nourish a self-respect: a job, a friend, a neighbor, a lover. This is the true lifeblood, and it is this that incessant mental disease steals.

Ernest Hemingway lost his hope. He declared, after a successful series of ECT treatments at the Mayo Clinic, "It was a brilliant cure, but we lost the patient." He committed suicide days after he was released from the clinic. Thankfully, ECT has kept my monster at bay, my hope intact. And science, with exciting new somatic treatments for mental illness, such as transcranial magnetic stimulation and vagus nerve stimulation, inches closer to the how and why of mental illness.

Thanks to the efficacy of ECT and the hope of less invasive, more advanced therapies, I need not die already dead.

Mr. Hartmann is a lawyer and a writer who lives in western Massachusetts. Jeffrey L. Geller, M.D., M.P.H., is editor of this column.




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