Got the power … Shirley Ball says ECT “rebooted” her brain in a way that medication could not. Photo: Tamara Dean
Electroconvulsive therapy is providing a jolt from the blues for many suffering from mental illnesses. Tim Elliott explores the resurgence of a much-maligned medical treatment.
One night in April, 1999, Shirley Ball found herself lying in bed beside her husband at 4am, staring into the darkness and thinking of ways to kill Amy, her four-month-old daughter. A pillow over the face - that would do it. What would happen if she put Amy in the microwave? The thoughts, which came from inside her head but weren't hers, terrified Ball, who lay there, just like the night before and the night before that, pinned to the bed, waiting for the dawn. "In the morning it was always this huge relief. I'd think: 'I'm safe again for another day.'"
'If that baby cries one more time, I'll scream.' A moment later, the baby cried, and Ball screamed. And screamed, and screamed, and screamed
Ball is 52 now, and lives in Sydney, where she works as an optical dispenser. A tall, slim woman with green eyes and blonde hair, she was raised by strict parents in a family that "appeared normal on the surface" but was riddled with mental illness: her two older brothers and younger sister had all been treated for various depressive conditions; some had been hospitalised. Ball considered herself "the lucky one", having arrived at adulthood with barely a down day. That all changed at the age of 38, however, with the birth of little Amy.
Lady with the amps … pioneering ECT specialist Professor Colleen Loo. Photo: James Brickwood
"It all began in hospital, when I couldn't sleep," Ball says. "I went home, and then, after six days without proper sleep, I began to feel euphorically happy, like I wasn't part of my body, like I was someone else.”
She began to have strange thoughts - "Have I had my baby?", "Is that my baby?" - and to feel that she possessed a psychic ability. Two nights later, she and her husband were at a work function when Ball complained of feeling "even more strange". "Everything was slowing down," she says. "I couldn't talk properly and even walking got harder." Returning home, Ball had her dinner fed to her and was put to bed, where she told her husband: "If that baby cries one more time, I'll scream." A moment later, the baby cried, and Ball screamed. And screamed, and screamed, and screamed.
After Ball had been shrieking, non-stop, for an hour, her husband called a friend, who happened to be a psychologist. The friend immediately called a mental health crisis team, but it wasn't until midnight that a nurse arrived, whereupon she determined that Ball was suffering post-natal psychosis, and admitted her to Royal North Shore Hospital.
Memory bit … GP Dr John McAuliffe has returned for further ECT treatments. Photo: Frances Andrijich
At the hospital, Ball became terrified of red and pink, colours that she suddenly associated with blood. "I could only talk to people who were dressed in blue," she says. Staff took her to her room, but when it turned out to be painted pink, Ball became hysterical and had to be sedated.
After two weeks in hospital, Ball was released on a course of antipsychotic medication. But the worst was yet to come. Over the following weeks, then months, she found herself sucked into an obliterating vortex of delusions, paranoia and depression. Despite the antipsychotics, she still couldn't sleep, and found it difficult to distinguish between dreams and reality. Then came the depression, an asphyxiating dread that proved similarly immune to medication. "I couldn't function. I'd drive to the shopping centre but then not know what to buy, so I'd walk around and walk out, sit down and cry in the car, then forget to the shut the boot and drive off.”
Admitted to Hornsby Hospital, she became convinced the staff were filming her and so, feigning normality, she got herself released. At home, she received daily visits from a psychiatric nurse, and remained on medication. And yet she increasingly thought of nothing but death, of killing her daughter, her husband, herself.
Lest she forget … lawyer Mariana Oppermann feels ECT damaged her memory. Photo: Andrew Campbell
Fearing for their safety, she sent her husband and Amy away, and after drafting up plans for suicide, made one last call to a friend. "He got me in to see a new psychiatrist," Ball explains, "who had me admitted to St John of God Hospital, in Burwood.”
Doctors at the hospital told Ball she was a candidate for electroconvulsive therapy (ECT). The procedure would involve passing an electrical current through her brain in order to trigger a seizure. "They told me, 'There are negatives.' I said, 'Like what?' And they said, 'With short-term memory; you might not remember all your time here.' And I said, 'What, and you mean that's a bad thing?'"
Ball can't remember the treatments, which then, as now, were given under general anaesthetic. But she knows she only had two, and that after the first one, she felt better "overnight". A few days later she received another dose, after which she felt better still.
"Before, my brain was like a locked computer," she says. "The ECT rebooted it, so that suddenly the thoughts, instead of being too many, were coming at a speed I could cope with.”
Twelve years later, Ball is happy and whole. She hasn't had any relapses and is not on medication. "It's amazing," she says. "Electroshock therapy saved my life.”
With the possible exception of lobotomies and blood-letting, it's difficult to think of a medical treatment more widely maligned than ECT, the mention of which brings to mind a punitive, almost medieval procedure involving straps and electrodes, a last-resort therapy administered in hospital basements where no-one can hear you scream. But as I recently discovered while watching ECT at a private hospital in Sydney, it's not nearly that dramatic.
The patient, whom I'll call Carol, is an elderly woman whose depression has not responded to medication. When I meet Carol, she is lying on a trolley in the treatment room, staring at the ceiling while her doctor, ECT specialist Professor Colleen Loo, attaches brain monitors to her temples.
For a procedure of such ghastly renown, ECT is remarkably quick. Carol is given a short-acting general anaesthetic, followed by a muscle-relaxant. Once she is unconscious, a mouthguard is slipped between her teeth. Loo then smears one end of the electrodes - two small plastic batons - with conductive gel, before placing them on Carol's head: one on the right temple, one on the crown. When the power is switched on - 800 milliamps for three seconds - Carol clamps down on the mouthguard; her head jerks back and her neck arches, but, thanks to the muscle relaxant, there is no grunting or thrashing about. All that remains is to monitor the resulting seizure, which in Carol's case lasts for 40 seconds and is accompanied by nothing more than a twitch of her left foot. Within moments, the anaesthetic wears off, and Carol's eyes are fluttering open. Barely 10 minutes have passed, and the procedure is over.
Loo is a tiny woman with a penchant for dark satin jackets and long work days. A psychiatrist and researcher at UNSW's School of Psychiatry and the Black Dog Institute, she is, in her mid-40s, an international authority on ECT, which she has been carrying out for 20 years.
"When I first started giving ECT, it was much simpler," Loo says. "We gave exactly the same electrical stimulus to all patients, for all treatments. But in the past 20 years, we've learnt how to individualise the treatment according to the patient's condition and seizure threshold, which means we can get the right balance between effectiveness and side effects.”
Those side effects - headaches, short-term memory loss and, in some cases, difficulty making new memories - do still occur. And yet ECT has come a long way, particularly in Australia, where it was first practised in 1941 at Adelaide's Glenside Hospital, on a machine built by the Superintendent of Mental Institutions, Dr Hugh Birch, from "meagre technical information" and bits and pieces of electrical equipment. ("Extreme caution was necessary," Birch later wrote, "as the apparatus was constructed by myself, a mere amateur, and not by any electro-medical company.")
These days, ECT is considered, in the words of veteran clinician and Sydney University psychiatry lecturer, Dr Bill Lyndon, as "the most powerful antidepressant we have." Studies have shown it to be remarkably effective in treating severe depressive, schizophrenia and manic or psychotic symptoms, with a response rate of 70 to 80 per cent (versus 50 per cent for most medications). Not only that, but ECT is fast. "Medications can take a number of weeks to work," Loo says. "With ECT, we are looking at half that time.”
The severely depressed can suffer not only morbid anxiety and suicidal melancholy - what writer William Styron described as a "horrified sense of ... interior doom" - but a near-paralysis known as psychomotor retardation; patients stop eating and drinking, their bowels shut down, they can't talk, sleep or dress themselves. In these circumstances, talk therapies are next to useless; nor do doctors have time to let medications kick in. ECT, then, can prove crucial.
But ECT is also used where patients with ongoing depression find medications ineffective, or find the side effects from those medications intolerable. Recently, Loo even gave ECT to a woman with catatonic schizophrenia: "Her condition was quite dangerous," Loo says. "She was 'freezing' in the middle of the road, and also when she went to the bathroom. She had not responded well to medication, but she did to ECT.”
Beyond the understandable reluctance of a patient to have someone electrify their cranium, scepticism about ECT can best be summed up in six words: One Flew Over the Cuckoo's Nest. Unflattering portrayals of the treatment have featured in print, most notably in the 1963 novel, The Bell Jar, by American poet Sylvia Plath, who received ECT in the early 1950s. ("Whee-ee-ee-ee-ee, it shrilled, through an air crackling with blue light," she wrote, "and with each flash a great jolt drubbed me till I thought my bones would break and the sap fly out of me like a split plant.")
But it was the 1975 film that sealed the deal, with its scenes of Randle McMurphy (Jack Nicholson) being fried alive, his torso bucking, his face white-lipped and gasping.
Notwithstanding the fact that anaesthetic and muscle-relaxants have been used in shock therapy since the 1950s, the images stuck, thereby "doing for ECT", to quote British psychiatrist Dr Susan Benbow, "what Jaws did for sharks".
In the decade following Cuckoo's Nest, ECT virtually disappeared, before staging a quiet comeback in the 1990s. These days, despite public misgivings, ECT use continues to rise: almost 26,000 treatments were given in Australia in 2011, up from 19,000 in 2007. (A course of ECT commonly consists of three treatments a week for three to four weeks.)
And yet even advocates of ECT concede that a rise in treatments is not without costs. Mariana Oppermann is a 33-year-old lawyer who lives in Canberra. In 2008, after repeated hospitalisations for depression and a suicide attempt, she was ordered to undergo several courses of ECT. (This is not unusual: more than 200 people received involuntary ECT in NSW last year.) Whatever initial benefits the ECT provided soon wore off, leaving Oppermann not only more depressed but cognitively "devastated". Her memory evaporated; for a short time during treatment, she was unable to talk. At the recommendation of her doctor, she returned to work, but was promptly asked to resign. "I couldn't remember the law or my clients; my boss said I was having difficulty using simple things around the office.”
What really hurts, she says, is the long-term impact. "I had ECT in 2008, and I don't remember almost any of the three jobs I had before that. I don't remember my legal training - a $15,000 post-grad qualification that I don't remember doing! I have first-class honours in law, but I can't remember what the honours were about.”
Old friends come up and say hello, but Oppermann can't remember them. "I have holidays that I've been on that I can't remember: I see photos of them, but to me it looks like I was Photoshopped into them. I've tried returning to those places to try to trigger memories, but it doesn't really work.”
There appears to be no pattern to the memory loss: Oppermann remembers flavours well, and some friends better than others. "I can even draw you a map of an office I had in a job I have no memory of having." While she accepts that ECT has a place - "I know people who've had good experiences with it" - Oppermann believes that doctors routinely downplay the negatives while overstating the positives.
And yet the sheer array of experiences - good, bad and horrific - make risk-benefit analysis fiendishly difficult, particularly as some people inherently cope better than others.
"My memory loss [from ECT] is relatively severe," Perth GP Dr John McAuliffe says. "But I've learnt some techniques, like 'memory aids', to help me get back to work faster.”
In the early 1990s, McAuliffe, who is now 50, was married with two young children. He was working as a GP in Perth, but also owned several medical centres and was, in his spare time, playing the sharemarket. When a trade went bad, however, McAuliffe lost $200,000 in a single day. Panicked, he set about selling the medical centres to cover the losses. "At the same time, my marriage was falling apart."
McAuliffe had always been a "big character", but the stress now tipped him into a full-blown manic episode, which culminated with him walking onto the tarmac at Perth International Airport and getting arrested by federal police. "It was my 31st birthday," he says, "and I got it into my head that I'd fly away on holiday.”
After receiving ECT at Joondalup Private Hospital, McAuliffe recovered. He has had it several times since, the last being a year ago. "I still work as a GP," he says. "I wasn't deregistered, because the medical board understands that I'm a responsible doctor who seeks treatment when I'm unwell.”
Memory is "an issue" for the first couple of weeks after treatment, so McAuliffe keeps particularly detailed records of case histories and conditions. "I also tell all my patients that I have bipolar. Some people don't come back, but for every one that leaves, you pick up a dozen who hear about you and like the frankness. It helps them relax.”
The therapeutic benefits of seizures have been known for millennia, with Hippocrates recognising as far back as the 5th century BC that malarial convulsions could cure the insane. But the first researcher to systematically pursue the link between fever seizures and mental illness was the Austrian professor (and later enthusiastic Nazi) Julius Wagner-Jauregg.
As a young doctor in the 1880s, Wagner-Jauregg observed how mental patients improved after surviving a severe fever. Early attempts to induce fever by infecting patients with typhoid proved unsuccessful. He kept going, however, and in 1917 took the radical step of injecting malaria-infected blood into nine men who were already suffering from chronic paresis, or syphilitic madness. The results - complete recovery in four patients and an improvement in two - led to a malaria treatment for paresis that eventually won Wagner-Jauregg the Nobel Prize for Medicine in 1927.
By this time, other doctors were experimenting with seizures; some used insulin overdoses, others used chemicals. Then, in 1937, an Italian neurologist called Ugo Cerletti suggested electricity. Even by the standards of the day, zapping mentally ill patients was highly experimental: curious physicians at Cerletti's clinic in Rome would be summoned bedside to witness the treatments by two short blasts of a trumpet.
But while ECT proved spectacularly successful in relieving depression, it was physically brutal, sometimes resulting in shattered teeth, broken backs and bone fractures. To counter this, doctors restrained their patients with bed sheets or weighed them down with sandbags, or even, in the 1940s, paralysed them with curare, the toxin used by Amazonian tribes on their blowpipe darts.
These days, there are no sheets or curare, and definitely no more trumpets. EEG monitoring, anaesthetics, synthetic muscle relaxants and more sophisticated delivery systems have transformed the procedure into something that is surpassingly mundane and relatively safe. One of the biggest changes in the past five years has been the introduction of ultrabrief pulsewidth ECT, which uses one-third the normal current. ("It's gentler," Loo says, "so you have less side effects.")
Yet doctors remain unable to explain exactly how these treatments work. It's clear that ECT boosts blood flow to the brain, but the most profound changes occur on a nerve-cell level. By stimulating the release of a protein called brain-derived neurotrophic factor, ECT not only promotes the birth of new neurons but aids neuronal regrowth, restoring to the brain cells the myriad tree-like projections that shrink back and wither in depressed people. Whether it is the electricity or the seizure that does this, nobody can say, a fact that critics are quick to pounce on.
"We know a lot about how it works," Loo says. "But it's like a billion-piece jigsaw puzzle. Just because I can't tell you where every single piece goes doesn't mean the treatment isn't valid.”
Besides, she says, no-one understands exactly how a general anaesthetic works, but "you wouldn't have your leg amputated without one".
At a residential psychiatric clinic in Sydney I meet Toby, three days after he has finished a month-long course of ECT. He speaks slowly, plucking words from his cobbled cognition like a toddler clutching at bubbles. "Basically when you go to remember something, you can't find it, and then when you do remember it, then you actually put that into long-term memory, and everything is sweet.”
Toby's problems began six years ago, when his 30-year marriage fell apart. He remarried two years later, but he and his new partner were "given grief" by his own children, which contributed to his breakdown. He had ECT then, and it worked. But he relapsed about three months ago, and had to be admitted again.
He is not 100 percent, he says, but he's no longer suicidal. He can talk. He's back to eating. The ECT has given him, "an opportunity to be, to be..." He pauses. "Well, it gives you light at the end of the tunnel.”
It gives you an opportunity to be better, I say.
"Yes, that's it," he says, with a flicker of a smile. "Better."
Contact Lifeline Australia on 13 11 14.
Like Good Weekend on Facebook to get regular updates on upcoming stories and events www.facebook.com/GoodWeekendMagazine