Powerful new implants and injections could soon revolutionize the treatment of schizophrenia and address the perennial concern of doctors and families that patients who stop taking their medicines may relapse into psychotic behavior. The new techniques could deliver medicine for weeks or even months at a time.

Proponents say such treatments, now in varying stages of development, could eliminate problems with patient compliance if they become widely prescribed.

The new techniques are collectively known as "long-acting" medicines because they involve injections that last for long periods and implants that release drugs slowly. The treatments will not cure schizophrenia, but doctors say they can help patients control their illness, with its delusional or disordered thinking and hallucinations, because they won't have to remember to take their medicine nearly as often.

Some advocates for the mentally ill are worried that new approaches could lead to coercive treatment. Proponents say the new technologies can increase patient choice while lowering the risk of side effects.

"Because it's a mental illness, there is much more fear of coercion," said John M. Kane, chairman of psychiatry at Zucker Hillside Hospital in Glen Oaks, N.Y. "But I think that may not take into consideration the nature of these diseases and how devastating they can be and how critical it is to prevent relapses and rehospitalization."

The antipsychotic medicines currently approved in injectable form in the United States come from an older class of drugs that cause severe side effects in many patients. Newer medicines called atypical antipsychotics have largely replaced the earlier drugs, but have not yet been made available in a long-acting form.

Now, Janssen Pharmaceutica Products L.P., the maker of risperidone, the country's most frequently prescribed atypical antipsychotic, is applying to the Food and Drug Administration to market an injectable version. Janssen said injectable risperidone has been approved in the United Kingdom, Germany, Austria, New Zealand, Mexico, the Netherlands and Switzerland.

Steven Siegel, a psychiatrist at the University of Pennsylvania, recently unveiled a device the size of a quarter that could be implanted in patients with schizophrenia. Siegel hopes the implants, which have yet to be tested in humans, could one day deliver antipsychotic medicine for a year at a time.

Trend Continues

It is difficult to predict when long-acting antipsychotics with the latest drugs might reach the market - but the trend toward these products is unmistakably on the horizon.

"In schizophrenia, we know that by the end of two years, 75 percent of people are not taking their medicine," said Samuel Keith, chairman of psychiatry at the University of New Mexico in Albuquerque, and a former chief of schizophrenia research at the National Institute of Mental Health.

Keith said everyone finds taking medicine difficult - people given a course of antibiotics often find they have a couple of unused pills by the last day. With schizophrenia, this forgetfulness can be compounded by the delusional and disordered thinking that are hallmarks of the illness.

"There is a part of logic that says, 'If I don't take a medication, that proves I don't have the illness,' " said Keith, who has helped test the injectable form of risperidone for Janssen.

"So someone with schizophrenia will say, 'I'm not going to take my medicine,' and the next morning they don't feel different, so they don't take it that day, either. For a couple of months, you can get away with it, but ultimately you will relapse."

Relapses can be terrifying and involve patients' hearing voices, seeing hallucinations and being unable to distinguish illusion from reality. Doctors say each relapse takes something from patients, leaving them with a longer, harder climb back to normalcy.

Kane said that hospitalizations, suicidal or aggressive behavior, homelessness, and lost jobs can follow. "Within a year, about 60 to 75 percent [of patients] will relapse without medication," he said in an interview.

Psychiatrist's Input

A major reason psychiatrists like long-acting medicines is that they facilitate monitoring patients since the implants would be put in place by a surgeon and injections would be administered by a nurse or another professional.

"If someone is on oral medicines, they could stop taking their medicines, and no one would know," said Kane, who also helped to test the injectable form of risperidone.

If a patient did not show up for an injection, however, Kane said doctors would have a couple of weeks, during which the previous shot was still potent, to make arrangements to bring in the patient for the follow-up injection.

The prospect of such techniques is raising concerns among some patients that the new treatments will be used coercively, effectively replacing the locked wards of mental institutions with what one advocate called a chemical straitjacket.

As states consider shifting laws that allow the forcible hospitalization of some psychotic patients to laws that force outpatient treatment, these advocates worry that injectable medicines may get used against the wishes of large numbers of patients.

"We hate the word 'compliance,' because it makes it sound like we have to be good little boys and girls," said Nancy Lee Head, who has schizophrenia and runs support group programs in Washington for the National Alliance for the Mentally Ill and the DC Mental Health Consumers' League.

Patients with schizophrenia, she said, want to be in charge of their treatment, just as patients with physical ailments manage their heart conditions or cancers. "Compliance is complying with what someone else has decided. If we are managing the illness, we are in charge."

Head questioned the need to have doctors administer the injections to keep tabs on patients. She cited her own management of diabetes: After she went on oral risperidone, she gained 45 pounds and had to start diabetes medicines - one of the side effects of atypical antipsychotics is weight gain. Head pointed out that diabetics are given the responsibility of injecting themselves, even though not taking medicine could have serious consequences.

Head said she was open to simplifying her medical regimen with injections - she was once on 64 pills a day. Having had relapses, she knows the terrifying feeling of being cut off from reality: She once asked her doctor, "Is my hand real?" and sometimes has felt so deadened by her illness that she has cut her hand just to feel something.

Forced Treatment Concerns

But Head is deeply uneasy about forced treatment. Although doctors may think forcing patients to take medicine is a form of compassion, Head said coercive treatment only added to her feelings of paranoia and helplessness.

Joseph A. Rogers, executive director of the Mental Health Association of Southeastern Pennsylvania, himself a patient with bipolar disorder, said he was not opposed to new treatments. However, he said he is concerned that pharmaceutical company marketing and doctors' talk about compliance would obscure the reality that the mental health system feels broken to many people with serious illnesses.

Patients on a biweekly injection regimen, for instance, might not have enough contact with doctors to discuss side effects, he said. "We're making it easier for states and local governments to find a cost-effective way to control people instead of treating people."

If patients are not given the right to "refuse these medicines, we could be creating a chemical straitjacket," he added.

Doctors such as Keith and Kane said they hoped the medicines would be given to patients with full informed consent. In fact, having patients decide to take an injection while they were healthy and capable of making a good decision ensured they would not deal with decisions about pills while experiencing mental distress.

Both doctors and patients agree that one of the greatest benefits of long-acting medicines is reduced side effects. Pills produce chemical peaks and troughs in the body, as the level of medicine fluctuates around the optimal level. The peaks tend to produce side effects.

Injections and implants, on the other hand, can deliver a steadier stream of medicine, smoothing out the peaks and troughs. Keith said the 4-milligram injectable form of risperidone, for instance, could deliver as much potency as a 25-milligram tablet, with the side-effect profile of only a 1-milligram tablet.

Ultimately, the effectiveness of the new techniques may depend less on the science and technology of the implants and injections, and more on realigning attitudes toward the treatment of schizophrenia.

"Implantable drugs may do an end run around compliance issues in the short term, but they'll do nothing to empower consumers to take part in their recovery," said Robert Bernstein, executive director of the Bazelon Center for Mental Health Law, an advocacy group.

Depending on how doctors and patients work together, he said, "Injectable psychotropics may be seen as an instrument of control, or as a more convenient way of taking medicine that consumers are already on."

In Europe, Keith said 30 percent to 50 percent of patients with schizophrenia receive long-acting antipsychotic injections: "It tends to go to the best patients because it's the best treatment available."

By contrast, barely 5 percent of American patients have tried the injectable version of the older drugs, and they have mostly been desperate patients. Siegel, the Penn psychiatrist, traced the roots of patients' concerns about coercion to the period in psychiatry when people with schizophrenia were seen as social problems to be controlled, instead of patients with a medical ailment who needed help.

"There is still a segment of the population that has a profound mistrust of psychiatry," he said. "We need people to understand we are not trying to do things to them, but things for them."

Source: By Shankar Vedantam, The Washington Post, Nov. 16, 2002

Hundreds of patients given shock treatment without their consent

Campaign: Medical professionals voice concern over standard of clinics using electro-convulsive therapy

By Sophie Goodchild Home Affairs Correspondent
13 October 2002
The Independent - UK

Hundreds of mentally ill people are being given electric shock treatment without their consent, the Government has admitted.

A new study shows that 2,800 people received shock therapy in a three-month period. Nearly 70 per cent of them were women.

The figures, published by the Department of Health, are revealed in research on the use of electro-convulsive therapy (ECT) in NHS hospitals and private clinics. The study was carried out between January and March 1999 but the figures were only released officially last week.

ECT is a controversial treatment used in cases of severe depression and involves doctors passing an electric current through electrodes attached to a patient's head.

Mind, the mental health charity, said that ECT should be banned in cases involving children and teenagers. They also believe that treatment should only be compulsory for patients unable to make their own choices. "There are lots of areas for concern, especially around the amount of information given to patients, the issue of consent and the type of machines used to deliver ECT treatment," said Alison Hobbs, a policy officer for the charity.

Of the 700 patients in the study who were detained and received ECT, 59 per cent had not consented to treatment.

ECT has been used since the 1930s, although there is still no accepted medical theory to explain how the treatment relieves the symptoms of mental illness. Patients are given a general anaesthetic and muscle relaxants. An electric current is then passed through the brain to induce a seizure similar to an epileptic fit.

Psychiatrists believe ECT is necessary for extreme cases, such as severe depression where patients are a suicide risk or refuse to eat and drink.

However, mental health campaigners are concerned about the levels of electric current used in treatment. In some cases, these are understood to exceed those allowed in other countries, such as the US. The amount of current needed to induce a seizure can vary hugely between individual patients. Clinical studies have shown that ECT can cause side effects including memory loss as well as impaired speech and writing skills.

The Royal College of Psychiatrists has carried out research which revealed that at least one in three clinics were rated below the standards required for provision of ECT treatment.

The National Institute for Clinical Excellence (Nice) is expected to publish new guidelines later this year, including the recommendation that doctors restrict the use of ECT on children and young people.

However, mental health campaigners said the Nice guidelines fail to provide adequate protection for the mentally ill.

Helen Crane has undergone ECT treatment on two separate occasions and has suffered severe side effects such as memory loss, slurred speech and loss of co-ordination. In her opinion, the controversial treatment should only be used by experienced mental health nurses and as a last resort when all other treatments have failed.

Mrs Crane, 55, agreed to treatment after suffering from severe depression several years ago. Now, she often gets lost around the town centre of Ashstead, Surrey, where she has lived for many years.

"I think the fact that patients are treated without consent is barbaric," Mrs Crane said. "If there was an orthopaedic treatment like this, for example, there would be a huge outcry. I think ECT should be a last-resort treatment."

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Job loss and the resulting financial strain can lead to depression and strain on relationships, lost personal control, lowered self-esteem.

While it may not be surprising that job loss and the resulting financial strain can lead to depression, new study findings show that this and other negative consequences of unemployment can last for up to 2 years, even after a person gets another job.

It is not simply the loss of employment that keeps individuals in a prolonged state of depression or otherwise poor health, the report indicates, but rather the "cascade of negative events" that follows that loss.

"It is the crises that follow job loss that are more damaging than the loss itself," says study author Dr. Richard H. Price of the University of Michigan, Ann Arbor.

Price and his colleagues investigated the link between job loss and depression, impaired functioning and poor health in a study of 756 job-seekers who were involuntarily unemployed for roughly 3 months or less and had no hopes of being recalled to their former position. The study participants were 36 years old, on average, and most had completed high school.

Overall, the financial strain that resulted from the participants' unemployment led to what Price called a "cascade of negative life events."

For example, if someone loses their job, they may have difficulty making a car payment, which can cause them to lose their car, thus hindering their ability to search for a job, the author explained. In addition, losing healthcare benefits due to unemployment will affect the person's ability to care for a family member with a life-long illness, all of which can create a "huge strain on relationships," Price said.

Such negative events seem to have caused the study participants to have higher symptoms of depression and a greater perception that they had lost personal control, including lowered self-esteem, study findings indicate.

Further, this depression and perceived loss of personal control remained evident in follow-ups conducted 6 months and 2 years later, when 60% and 71% of the study participants, respectively, had been re-employed and were working at least 20 hours a week, Price and his team report in the current issue of the Journal of Occupational Health Psychology.

What's more, the study participants' perceived loss of personal control led to reports of poor health and poor emotional functioning in daily tasks, both of which also remained evident in subsequent follow-ups, the researchers note.

"Some effects reflected in disability and depression linger for some people," Price said. Also, the "sense of job security is eroded," which Price says is "another hidden cost of job loss."

Finally, the participants' depression appeared to affect their later chances of reemployment, study findings indicate.

"These people become 'discouraged workers,' not searching for a job, and the personal, family and societal costs are very high," Price said.

"Thus, chains of adversity are clearly complex and may contain spirals of disadvantage that reduce the life chances of vulnerable individuals still further," the researchers write.

Yet, much of these negative effects "can be prevented in many cases by helping people learn the skills of getting back into the labor market," Price said.

And to those who are currently exercising those skills, Price offers the following advice: "Help inoculate yourself against inevitable setbacks and turndown by planning your strategy beforehand for what you will do if this try doesn't work out. Always try to have a 'Plan B."'

The study was funded by the National Institute of Mental Health through a grant to the Michigan Prevention Research Center.

Source: Journal of Occupational Health Psychology 2002;7:302-312.

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Eight years ago, 60-year-old Ernie Pohlhaus slumped behind the wheel of his car and told his wife he couldn't drive. Later that night, he was convinced that FBI agents had surrounded their house. The next morning, Ernie was sure he was going to die from kidney pain. He was taken to the emergency room. After an onslaught of tests, doctors realized he was experiencing a psychotic episode brought on by depression. He was eventually diagnosed with bipolar disorder. Ernie had been a happy, healthy man, a few years from retirement.

Ernie's illness shook the family emotionally and financially. To avoid the stigma of being mentally ill, he retired without disability. Thereafter, he lost much of his pension benefits. While his children, John and Jeanine, moved back home to support him through the first difficult months, Ernie has depended mainly on Joan, his wife, for strength. During the past eight years, Joan has worked off and on as a director for an educational learning center, but she stays home with Ernie when he lapses into depression. Although things have changed, the little routines of daily life keep her going.

Two weeks after Ernie entered the emergency room, his doctors announced that there's nothing physically wrong with him. They recommended psychiatric help. The next day, John drove Ernie to Philhaven Hospital. Ernie didn't know where he was going or why. He was unable to speak or even smile. He just knew that he was sick and he couldn't go home. While his wife held him, Ernie was in a different world.

Ernie was once an energetic social worker for the state of Pennsylvania. His condition, however, changed all that. Joan tried to explain to her husband that his depression was causing his sickness and that he was too ill to go home. But he was hurting too much to understand what she was saying. The next day, he signed into Philhaven Hospital.

Ernie stayed at Philhaven for a few months. After sampling an endless list of antipsychotic drugs and antidepressants, he was still depressed. Time was running out-his insurance coverage would expire in a few days. The insurance company and his doctor persuaded Ernie to try electroshock therapy before the coverage ran out. He decided to undergo treatment. To ensure his body could withstand the shock, he was given several tests, including an electrocardiogram. In all, he had 13 electroshock therapy sessions.

For the Pohlhauses, electroshock therapy sounded like something out of a horror movie. But the doctors recommended it. The nurse at the psychiatric hospital led them into the recreation room and turned on a video about the treatment. Ernie watched the tape in a drugged stupor. Joan tried to hold him, but his body was rigid.

Home from the hospital, Ernie took to his bed for months. With his family's encouragement, he gradually started seeing friends once a week. He and Joan visited Jeanine in New York. They took the subway to see the Christmas lights at Rockefeller Center. City life, though, was overwhelming and Ernie tired easily. Back home, he took on a full-time job teaching German at a local high school. His family was thrilled. But he earned only one paycheck. Joan knew he wasn't going to work but didn't embarrass him with questions. One day, she dropped him at the school and watched him from the rearview mirror. He headed to a nearby diner, where he spent his day. Going to work exhausted him, but he couldn't face telling his family.

Ernie's family and friends have been both supportive and ignorant. His less-understanding friends look down on him and believe he could snap out of his depression if he tried. Joan's longtime friend, Lili Walters, was not one of them. Lili, a massage therapist who believes in alternative treatments, has stood by the family. She offers massages, advice or just an occasional helping hand.

On bad days, simple tasks can be frustratingly hard for Ernie. Joan asks him to help around the house, but he doesn't like being told what to do. And although Joan hates being a taskmaster, she feels she doesn't have much choice. Sometimes they argue, but apologies always follow.

Family dogs Sauza and Francis are therapeutic companions for Ernie. After the electroshock, he suffered manic episodes. At odd hours, he would drive for miles in his pajamas looking for oysters and gourmet food. During these episodes, Sauza, the 11-year-old boxer, would refuse to recognize Ernie. Later, Ernie knew he was recovering when Sauza began sleeping next to him again.

Ernie naps in the lobby of the Hotel Hershey after celebrating his 40th wedding anniversary. He's no longer depressed. He spends his spare time singing with the Harrisburg Choral Society, and his rendition of "Danny Boy" at the neighborhood bar has made him a local celebrity. Still, he hates his medication. The lithium (Lithium Carbonate) stabilizes him, but it also numbs his emotions. He's taking drugs for his diabetes and heart disease, as well. Used together, the prescriptions make him sick and exhausted. He spits out the pills when no one is watching. Other times, he just forgets to take them. Joan grows tired of policing Ernie-it puts a strain on their marriage. Together, they take the bad days with the good, trying to find value in each moment he feels well.

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Symptoms, causes, treatment of generalized anxiety disorder (GAD) and GAD self-test.

What is Generalized Anxiety Disorder (GAD) and how do you know if you have it? These questions are not always easy to answer. GAD is the least researched of the anxiety disorders. It was not recognized as a separate disorder until 1980, when the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) - the classification guide used by mental health professionals - was published by the American Psychiatric Association.

There are a number of reasons for GAD having gone unrecognized for so long. First, many of the symptoms of GAD overlap with the symptoms of other anxiety disorders. Second, the physical symptoms of GAD mimic those of several medical conditions, often making it difficult to diagnose. Third, GAD tends to have a high rate of comorbidity - meaning that it can occur with other anxiety disorders as well as with depressive disorders.

The identifying characteristic of GAD is excessive uncontrollable worry that affects daily functioning and can cause physical symptoms. The sufferer worries everyday, sometimes all day, to the point where it feels as though the worry has taken over. Worrying takes so much time and energy that it can be difficult to concentrate on anything else. The focus of GAD worry can shift, but usually centers on issues like job, finances, and the health of both self and family. It can also include more mundane issues such as chores, car repairs, and being late for appointments. Although the concerns may be realistic, a person with GAD will spin worry completely out of proportion. The National Comorbidity Survey, a study of the prevalence of psychiatric disorders carried out in the United States in the early 1990's, reported that one half of the people surveyed who had GAD said that it significantly interfered with their life and activities. Two thirds of the people interviewed sought the help of a professional.

Approximately 4 million Americans between the ages 18-54 have GAD, and women are twice as likely to have the disorder. People of either sex who are divorced, don't work outside of the home (homemakers and retirees, for example), or who live in the Northeast also appear to be more vulnerable to developing GAD. Income, race education and religion, on the other hand, do not seem to play a role in who develops the disorder.

What Is Worry?

Worry, also called "What if..." thinking, is pervasive in GAD. Thoughts such as, "What if I am late for the interview? "What if I don't do well on my math test?" constantly run through the mind of the GAD sufferer. To some degree, this type of thinking is a normal reaction to life - everyone has worries and concerns. Worry can even be beneficial. It can help people identify and cope with threats, and it can lead to problem solving. People with GAD, however, cannot control their worrisome thoughts. They cannot help but think about multiple negative outcomes, none of which are likely to occur, while making no attempt to cope with their concerns. A student worried about a final exam, for example, may be motivated to study. Someone with GAD, however, may be so fearful of doing poorly on an exam that he/she can only concentrate his concern, essentially becoming paralyzed worry rather than motivated by it.

David Barlow, Ph.D., director of the Center for Anxiety and Related Disorders at Boston University, and the author of Anxiety and its Disorders: The Nature and Treatment of Anxiety and Panic, notes that since worry is common to all anxiety disorders, GAD may be the most basic anxiety disorder and that understanding it may lead to a better understanding of anxiety disorders in general. Unlike other anxiety disorders, in which the worries tend to be specific, such as the panic disorder sufferer worrying about having a panic attack, worry in GAD is more general, as the name of the disorder suggests. Individuals with GAD have even been known to worry about worrying, the term for this is "meta-worry."

Symptoms and Diagnosis

In order for a diagnosis of GAD to be made a person must experience excessive, uncontrollable worry about several issues for more days than not for at least six months. The worry must be accompanied by at least three of the following symptoms:

• restlessness, or feeling "edgy"
• being easily tired
• difficulty concentrating
• irritability
• muscle tension
• difficulty sleeping

The physical symptoms of GAD, which can include chest pains and irritable bowel syndrome, often prompt sufferers to see their primary care physicians. These physical symptoms are often treated first, which delays diagnosis of GAD. Another reason GAD may not be immediately recognized as an anxiety disorder is because it lacks some of the dramatic symptoms that are seen with other anxiety disorders, such as unprovoked panic attacks.

Onset of GAD can occur in childhood, but a stressful event, such as having a child, can also trigger the disorder later in life. The age of the person with GAD has been shown to have an impact on what the person worries about. Young children tend to worry about their physical well-being and safety, while older children are more concerned with their psychological well-being and overall competence. Adults over 65 reported worrying about becoming burdensome to their families, as well as having more health related worries than did adults between the ages 25-44.

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Treatment

An important step in the treatment of any anxiety disorder is learning about and understanding the disorder. This gives the patient a certain amount of control over their symptoms and it also helps them realize that others have had similar experiences. It is also very important to be able to make informed decisions about treatment. There are a variety of treatment options available for GAD, and more are currently being researched.

Medication is sometimes indicated in the treatment of anxiety disorders and has been proven effective in reducing the symptoms of anxiety. It can be especially effective when there is more than one anxiety disorder or when there is comorbid depression, as is often the case with GAD. The alleviation of anxiety symptoms can allow the patient to move forward with psychosocial therapies, which can work well in combination with medication.

Several psychosocial techniques have been proven effective in the treatment of anxiety disorders. Various techniques, known collectively as Cognitive Behavioral Therapy (CBT), have been shown to work well for GAD in particular, some of these techniques are: self-monitoring, cognitive therapy, and worry exposure.

Self-monitoring - the principle behind this technique is that the patient takes note of when he/she begins to feel anxious and records when and where the feelings began, their intensity and the symptoms. The goal is for the individual to become familiar with the patterns of his/her anxiety and worry.

Cognitive therapy - works to help the patient change his/her thought patterns. The goal here is the reappraisal of worry, leading the patient to think more realistically about his/her worry and negative thoughts. This includes changing thoughts that may actually promote worry, such as, "If I worry about it, it won't happen."

Worry exposure - requires that patients expose themselves to situations and ideas that worry them in order for them to both become used to the worry, and so that they can see that worrying and anxiety do not cause negative events.

With so many treatment options available, it is necessary that treatment be specially tailored to each individual. The best way to go about this is to see a mental health professional who specializes in the treatment of anxiety disorders.

TOM LYONS
Canadian Press
Saturday, September 28, 2002

TORONTO (CP) - Marianne Ueberschar checked herself in to the city's Centre for Addiction and Mental Health two years ago suffering from suicidal depression.

Like many older women entering psychiatric wards in Canada, Ueberschar, now 69, was offered electroconvulsive shock therapy, or ECT. She refused, and fought a legal battle with the institution to prevent it from administering the treatment.

"I said I don't want my brains fried, thank you very much," says Ueberschar, who was discharged five months later without having been hooked up to electrodes to induce a generalized seizure.

(Please see below for: In early years of ECT, most doctors didn't use it on seniors.)

Invented in the late 1930s, the treatment for mental disorders involves passing an electric current through the brain.

It has its supporters and detractors.

ECT is endorsed by the Canadian Psychiatric Association, the American Psychiatric Association, the American Medical Association, the U.S. Surgeon General, and the U.S. National Institute for Mental Health, or NIMH.

According to an article posted on the Toronto mental health centre's Web site, people have no substantial reason to fear the procedure because it doesn't cause "structural brain damage" and it has "come a long way from its first unmodified use in 1938, when it was administered without anesthesia and muscle relaxant."

A vocal minority of doctors, however, says the treatment is inherently unsafe for the elderly.

"It causes them to have memory problems when they've already got memory problems to start with. It causes increased cardiovascular risks. It causes falls which can lead to death when they break their hips," says Dr. Peter Breggin, a psychiatrist and author, speaking on the phone from his office in Bethesda, Md.

"It is ridiculous to give a brain-damaging treatment to people who are already having cognitive difficulties due to an aging brain."

The topic has also provoked a great deal of debate in New York State over the past year. In March, a standing committee of the New York Assembly released the results of a year long review that concluded elderly people were more likely to receive ECT.

Permanent cognitive deficits, memory loss, and premature death were among the increased risks from ECT faced by older people, said the report, which called for special safeguards for the elderly.

"The use of this controversial method of treatment is deeply disturbing, particularly when you consider that its use results in damage to the brain and lapses in memory," said Assemblyman Felix Ortiz, who is preparing a bill which would provide more protection for the elderly.

"The use seems almost ironic when you consider how many children and grandchildren wish there was a way they could save the memories of their parents and grandparents from diseases such as Alzheimer's."

ECT fell out of favour in the 1960s and '70s in the U.S., as psychiatrists increasingly turned to antidepressant medication, but has gradually made a comeback.

The American Psychiatric Association notes in its 2001 Task Force report that elderly people became the primary recipients of ECT across the U.S. in the 1980s.

"Individuals aged 65 and over received ECT at a higher rate than any other age group. Indeed, the overall increase in the use of ECT between 1980 and 1986 was fully attributable to its greater use in elderly patients," states the report.

"Further evidence for increased use of ECT in the elderly comes from a survey of Medicare Part B claims data between the years 1987 and 1992."

The Canadian Psychiatric Association hasn't published a comprehensive national survey of ECT use on the elderly, but partial statistics from several provinces suggest a similar situation in Canada.

About 13 per cent of the population here is over 65.

In British Columbia, people 65 years of age and over comprised 44 per cent of the 835 patients receiving ECT in 2001.

In Ontario, patients 65 and over accounted for 28 per cent of the 13,162 ECT treatments given in general hospitals and community psychiatric hospitals in 2000-01, and 40 per cent of the 2,983 ECT treatments given in provincial psychiatric hospitals in 1999-2000.

In Quebec last year, 2,861 of the 7,925 ECTs administered (about 36 per cent) were to people over age 65.

Figures from Nova Scotia for 2001-02 show a total of 408 ECT treatments, including 91 on people over 65.

Dr. Kiran Rabheru, the head of the geriatric psychiatry at the Regional Mental Health Centre of London, Ont., says the treatment is often safer for elderly depressed people than antidepressant medication or no treatment at all.

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"These are people who are so severely ill that without the treatment they would almost certainly die of the illness much faster and more certainly than with the risks," says Rabheru.

"Where someone actually comes in at death's door, and you give them a couple of ECTs, they start to eat, they start to drink, they become a lot less suicidal."

But he acknowledges it's more hazardous to older patients.

"The risks are definitely greater," says Rabheru, whose institution provided 79 per cent of its ECT treatments to patients over the age of 65 in 1999-2000, the last year for which statistics are available.

"Because they're more frail. Their cardiovascular systems are compromised, their respiratory systems are compromised. So the risks are definitely higher, no question about it. And there are people who have cognitive impairment, who have cardiac problems as a result of anesthesia."

Dr. Lee Coleman, a psychiatrist and author based in Berkeley, Calif., says "risk-benefit" analyses of ECT overstate the benefits and underestimate the hazards.

"What they never talk about is the people who commit suicide because they're afraid of the treatment that is about to be forced upon them. That definitely happens," says Coleman in a phone interview.

In a 1999 Journal of Clinical Psychiatry article, Dr. Harold Sackeim, a leading advocate of the treatment in the U.S., wrote: "Little, if any, evidence supports a long-term positive effect of ECT on suicide rates."

Keith Welch, a former president of the patients' council at the Queen Street Mental Health Centre in Toronto, now part of the CAMH, says he suffered a series of strokes and several years of memory loss after receiving ECT in the 1970s.

He feels that elderly patients are being damaged by ECT.

"When the seniors first go in, they're very active. Maybe a little upset, you know, because it could be a family problem, something like that. Then, maybe a month later, they're walking around like zombies. They don't know what's going on, Some of them can't even change their clothes after they get shock treatments," says Welch, 59.

"I always stop and figure, you know, someday I'm going to be as old as them too. What if the same thing happens to me?"

Don Weitz, 71, who has actively campaigned against ECT for years, notes that more older women than men receive the therapy in Ontario.

"Elderly women are such easy targets," he says.

"When part of the medical profession targets an age group of 60-plus, it's a form of elder abuse," says Weitz, an ex-insulin shock patient who lives in Toronto.

"The reason the elderly get so much ECT is because they are less likely to refuse. People as they get older generally automatically do what the doctor says without question. 'Shock docs' can make hundreds of dollars a day just by pressing a button."

Dr. David Conn, head of psychiatry at the Baycrest Centre for Geriatric Care in Toronto, says any notion that psychiatrists give ECT to the elderly to make money is incorrect.

"From a physician's perspective, you've got to get up early in the morning to give the treatments, and I'd prefer to stay in bed," says Conn, who adds that ECT is a "lifesaving" treatment for elderly people who suffer from suicidal depression but who are unable to tolerate antidepressant medication.

"There's no great advantage to physicians giving the treatment except that if you want your patients well, it works."

Treatments are usually administered in the morning because patients have to fast beforehand.

In December 2000, Dr. Jaime Paredes made headlines with his concerns about increased use of ECT at Riverview Hospital in Port Coquitlam, B.C., after doctors began receiving an extra $62 or so per treatment from the provincial health-care plan.

At the time, Riverview spokesman Alastair Gordon defended the increase, saying that the institution was receiving referrals from other hospitals and there was growing medical acceptance of ECT as a "treatment of choice for geriatric patients suffering from depression."

A review panel commissioned by former health minister Corky Evans found that ECT "delivery" at the hospital was of high quality, but the lack of a detailed database on outcomes meant there was no way to evaluate the results, or to determine why the number of treatments had jumped so dramatically.

Paredes resigned under pressure from his position as president of Riverview's medical staff in December 2001.

"The medical plan is impressed with an administrator who shortens patients' hospital stay and even if an ECT patient is readmitted fairly soon, he counts as a new admission, rather than the same patient having a long stay," Paredes said in an interview.

Earlier this year, Riverview was in the news again when Michael Matthews, a 70-year-old patient who had received 130 ECT treatments over a three-year period, made the front page of the Vancouver Sun.

"I don't like it. They hurt, I don't want it," Matthews told a reporter for the Sun, which ran a close-up photo of Matthews' head which was covered in cuts and bruises from a fall he said was caused by ECT-induced confusion.

The B.C. Public Guardian and Trustee's office and the B.C. Provincial Health Services Authority have both launched probes into Matthews' ECT treatments.

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Paredes, who was Matthews' doctor for several years before his ECT treatments began, says numerous elderly ECT recipients at Riverview are suffering from the same type of ECT-induced mental deterioration plaguing his former patient.

"There are many, many others. And nobody wants to talk (about) them. Because the relatives are always concerned that they're going to be blamed for allowing this to happen. And the patients, most of the time they are not in a condition to talk at all," says Paredes, who adds that he is not opposed to the appropriate use of ECT.

Dr. Nirmal Kang, the head of ECT services at Riverview, declined to discuss the Matthews case due to confidentiality, but he defended his hospital's ECT safety record in a telephone interview.

"From 1996, God forbid, we haven't had a single fatality related to ECT complications," said Kang.

That ECT can cause death from medical complications is conceded by proponents, but the frequency of ECT fatalities is hotly disputed.

Sackeim, an APA Task Force member and NIMH researcher, says elderly people have only a "somewhat higher" death rate than the APA's general mortality estimate of one in every 10,000 ECT patients, or 0.01 per cent.

"Just in general, the rate of mortality in ECT is low," says Sackeim from his office at the New York Institute of Psychiatry.

Opponents of ECT, like Dr. John Breeding, a Texas psychologist, say the actual death rate among elderly electroshock recipients is closer to one in 200 patients, or 0.5 per cent, judging from the number of post-ECT pathology reports filed in the 1990s in his state, the only jurisdiction in North America requiring the reporting of all deaths occurring within 14 days of ECT.

The current CPA position paper on ECT cites a general treatment complications rate for all ages of one in 1,400 treatments, or 0.07 per cent.

And the APA report says "reports of stroke (either hemorrhagic of ischemic) during or shortly after ECT are surprisingly rare."

Opponents say this overlooks strokes which occur as long-term complications in the elderly, as detailed in a 1994 case report by Dr. Patricia Blackburn, and disregards other types of ECT-related brain damage in older people, such as atrophy of the frontal lobes, found in a 1981 CAT scan study of 41 elderly patients by Dr. S.P. Calloway and a 2002 MRI study by Dr. P.J. Shah.

"(It's) a big lie ECT doesn't cause brain damage," Dr. John Friedberg, a California neurologist, told New York Assembly hearings on ECT in May of last year.

"One picture will refute that," he said, referring to an MRI scan published in the November 1991 issue of Neurology of a 69-year-old woman who suffered an intracerebral hemorrhage after ECT.

The 2001 APA report does include a reference to the woman's brain scan but the sample patient information booklet appended to the report nevertheless says "brain scans after ECT have shown no injury to the brain."

Dr. Barry Martin, head of ECT services at the CAMH in Toronto and a peer reviewer of the 2001 APA report, said it would be a "waste of time" to respond to the opponents' arguments because Breggin and Friedberg suffer from a "lack of credibility."

"The 'other side' is so inflammatory and out of touch with the realistic benefit of this treatment that it interferes with people getting effective treatment," Martin said. "Frightens people and their families unduly."

He said transient memory loss is well worth the price to someone who recovers from depression after undergoing ECT.

"The memory loss usually recovers over a period of weeks to several months," he said.

"There may be some permanent loss for some events both before and after the treatment. But for the ability to learn and retain new information, the actual memory mechanism recovers fully. If it didn't, ECT would not be allowed in treatment."

And Rabheru has noted some financial benefits to the health-care system.

"With the current economic constraints, governments and third party payers are under constant pressure to reduce expensive inpatient stays to a minimum, but also to provide optimum quality of psychiatric care," he wrote in a June 1997 article in the Canadian Journal of Psychiatry.

"C/MECT has been clearly shown to reduce inpatient stays in numerous studies."

C/MECT is continuation or maintenance ECT, and consists of ongoing treatments after the original course of six to 12 treatments is completed.

A report commissioned at arm's length by Health Canada, the provinces and territories, and released in January 2001, says government should become involved.

The study by Dr. Kimberly McEwan and Dr. Elliot Goldner of the University of British Columbia department of psychiatry recommended that health authorities begin measuring the percentage of ECT recipients who suffer strokes, heart attacks, respiratory problems and other recognized complications of the treatment.

Meanwhile, back in New York state, the standing committee's report has urged the U.S. Food and Drug Administration to conduct an independent medical safety investigation of ECT machines.

"The FDA has never tested ECT devices to ensure their safety," the report noted.

On May 30, the New York Assembly passed a resolution calling for an FDA investigation.

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Health Canada, like the FDA, has never conducted medical safety tests of ECT machines, nor has it required the ECT machine companies themselves to submit safety and effectiveness data.

"No performance and maintenance standards exist for ECT machines. The Bureau of Medical Devices has not tested ECT machines since there have not been any reported problems. The bureau has never inspected shock machines," wrote Dr. A.J. Liston, then assistant deputy minister of health, in a Feb. 4, 1986 response to questions raised by Weitz.

Health Canada spokesman Ryan Baker says there are no plans to conduct a medical safety investigation of the only ECT machine currently licensed for sale in Canada, the Somatics Thymatron, which was "grandfathered" into use without the submission of safety and effectiveness data sometime prior to 1998, when the current medical devices regulations were enacted.

"A lot of these questions come down to the practice of medicine, like the use of these devices. And Health Canada doesn't regulate that. We regulate the sales," says Baker.

In early years of ECT, most doctors didn't use it on seniors. Most doctors disapproved of the use of electroshock therapy on the elderly during the first era of the treatment, which began in 1940, when the "miracle cure" for mental disease was imported to America from Italy by Dr. David Impastato.

That so-called first era lasted until the late 1950s, when the treatment, also known as ECT, began to be supplanted by the new psychiatric drugs.

Impastato warned psychiatrists in 1940 not to shock patients over the age of 60, and his advice was generally heeded.

"The majority of physicians continue to be opposed to the application of electric convulsive therapy during the senium (sixty years and over)," reported Dr. Alfred Gallinek, a New York psychiatrist, in 1947.

An adventurous minority ignored Impastato's advice, however, with sometimes catastrophic results. In a 1957 survey, Impastato found that electroshock recipients over the age of 60 had a 15 to 40 times higher ECT fatality rate than younger patients (0.5 per cent to one per cent as opposed to 0.025 per cent to 0.033 per cent).

In Canada, where ECT was introduced in 1941, a similar split occurred.

Dr. A.L. Mackinnon, of The Homewood Sanitarium in Guelph, Ont., noted in 1948 that seniors comprised only seven per cent of his institution's electroshock recipients. Dr. John J. Geoghegan, of the Ontario Hospital at London, Ont., on the other hand, reported electroshocking seniors regularly with "excellent" results in 1947.

Still others tried it and regretted it.

"Shock therapy is dangerous therapy," warned Dr. Lorne Proctor, a Toronto psychiatrist, in 1945, after a 65-year-old man suffered a paralysing stroke from electroshock.

"The possibility of cerebral hemorrhage following stimulation of the frontal lobes by this technique is real."

Similarly, Dr. G.W. Fitzgerald, of the Regina General Hospital, reported the death of a 59-year-old farmer from ECT in 1948.

Dr. George Sisler, of the Winnipeg Psychopathic Hospital, reported the electroshock deaths of a 50-year-old farmer in 1949 and a 60-year-old office worker in 1952.

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SPECT scans are dangerous to children or adults with ADHD, and can cause cancer 10 or 20 years down the road even when only used once to "diagnose" ADHD. Here's how it works.

Are SPECT scans dangerous to children or adults when used to "diagnose" ADHD?

Imagine you're in one of those huge hotels with hundreds of windows facing out onto the parking lot. You walk to the window and look down and see a man with a rifle, waving it around as if he were thinking of spraying the entire building with bullets. And then you see the muzzle flash at the end of the rifle's barrel, hear the crack sound of the shot, and, a half-second later, the shattering sound of glass somewhere off to your right on that huge wall of glass.

Given that situation, would you get away from the window? Would you feel "safe"?

What if the hotel had a thousand windows instead of a few hundred, and you knew the shooter could only fire a few bullets before he ran out of ammunition?

What if the shooter was actually doing something that the hotel had requested - say, shooting pigeons off the roof because they were pesky or carried disease - and every now and then he missed the pigeons and hit a window? Would you feel safer because there was a reason for his shooting? Would you continue to stand in the window, knowing the odds were low that you'd be hit and the shooting was useful for the hotel's bird problem?

Better yet, would you put a child in the line of fire?

In order to make sense of this analogy, consider for a moment how radiation causes cancer.

The replication of cells is controlled by a small segment along a DNA double-helix. When something hits or damages the DNA in the cell, usually the cell simply dies. This is happening right now in millions of cells in your body as you read these words. The body is all set for it, with scavenger systems in place that recycle the cell's nutrients.

Occasionally, however, instead of DNA being hit in ways that kill off the cell, that one little window on the DNA strand that controls its reproduction gets damaged. The cell loses its ability to know when to stop reproducing, and starts dividing as fast as it can. This is called cancer.

The four main things in our world that "hit" DNA in ways that cause it to become non-reproducible (and also leading to the cell's demise) or super-reproducing (cancer) are oxygen-bearing chemicals (called "free radicals" or "oxidizers"), DNA-toxic chemicals (called "carcinogens," with the chemicals in cigarette smoke being the most familiar to most people), DNA-reproduction-stimulating compounds (called "hormones" and the hormone-mimickers such as those found in certain plasticizers, pesticides, and sun-blocking chemicals) and ionizing radiation (the most well-known being UV radiation in sunlight, which causes skin cancer, and X-rays, which can cause cancer anywhere).

In part because our sunlight has become more lethal in the past 50 years and our environment and foods filled with industry-created carcinogens and hormones, one-in-two men and one-in-three women will get cancer in their lifetimes. We take anti-oxidant vitamins like C and E to reduce the damage, eat natural foods to avoid the chemicals, and wear sun-block, all in efforts to avoid damage to our DNA that might flip "on" the reproduction switch in a cell so it turns to cancer.

Radioactivity is Not Only Dangerous, It Can Be Deadly

I remember when I was a child, walking home from school in the first grade in 1956. There was a shoe store on the way, and they had a really cool machine that I stuck my feet into dozens of times so I could see the bones in my toes and how the tissues of my foot fit my shoe. A friend of mine, now deceased from thyroid cancer, had radioactive radium pellets put into her sinus' to stop recurrent sore throats and tonsillitis. My mother was encouraged to step out of the house and into a truck that traveled around giving women breast x-rays. And they were exploding bombs above the ground in Nevada so frequently that more radiation was released on America than we released on Hiroshima and Nagasaki combined.

We've learned a lot since 1956. The shoe-store fluoroscopes are banned, doctors don't use radium anymore to treat sore throats, and almost all aboveground nuclear testing has been halted worldwide. We're even recommending that women under 40 not get annual mammograms, in part because of concern that the radiation from the x-rays may cause more cancer than it would find. A study cited in Science News a decade or more ago reported a correlation between the number of dental x-rays a person had as a child and the development of cancers of the mouth and neck in adult years, leading dentists to begin wrapping people's necks with lead aprons and to use tighter-beamed x-ray machines now in most dental practices (with a square, adjustable "gun" instead of a round scattershot beam).

The Impact of Radiation on Humans

Much of our current knowledge of the impact of radiation on humans comes from pioneering work done by Dr. John Gofman, Professor Emeritus of Medical Physics at the University of California at Berkeley, and Lecturer at the Department of Medicine, University of California School of Medicine at San Francisco. In the 1940s, while still a graduate student at Berkeley, Gofman made an international name for himself in the field of nuclear physics when he co-discovered protactinium-232 and uranium-232, protactinium-233 and uranium-233, and proved the slow and fast neutron fissionability of uranium-233, which made possible atomic bombs.

After receiving his PhD in nuclear physics, he went to work for the US Government to help develop the atomic bomb, and invented, along with Robert Oppenheimer and Robert Connick, the currently used process for extracting plutonium from irradiated uranyl nitrate. The bomb project finished, Gofman went back to college, this time to get his MD in 1946. In 1947, he transformed the world of heart disease prevention and treatment by developing a new flotation ultracentrifugal technique that discovered low-density lipoproteins (LDL) and high-density lipoproteins (HDL), and then he conducted the first prospective study demonstrating that high LDLs (also known as "bad cholesterol") presented a risk for heart disease and high HDLs (also now known as "good cholesterol") demonstrated a resilience against heart disease. He literally wrote the book on heart disease that's still today used in medical schools, "Coronary Heart Disease," published in first edition in 1959.

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Recognizing that Gofman understood both nuclear physics and human medicine, in the early 1960s the Kennedy administration asked him if he'd start a Biomedical Research Division at the Lawrence Livermore National Laboratory, and supervise research into survivors of the Japanese atomic-bomb attack, Americans who'd been exposed to atomic and X-ray radiation, and look into the suspected relationship between radiation, DNA/chromosomes, and cancer. Dr. Gofman ran the research division at Lawrence Livermore from 1963 to 1965, and the things he learned in his research began to trouble him. Other researchers were pursuing similar paths, with the publication in 1965, by Dr. Ian MacKenzie, of a report entitled "Breast Cancer Following Multiple Fluoroscopies" (British J. Of Cancer 19:1-8), and in 1963, Wanebo and co-workers report "Breast Cancer after Exposure to the Atomic Bombings of Hiroshima and Nagasaki" (New England J. Of Med. 279: 667-671). In a groundbreaking analysis of the studies extant at the time, Gofman and his colleague Dr. Arthur Tamplin concluded that even very low levels of radiation could cause human cancers, and published their research in the highly respected medical journal Lancet (1970, Lancet 1:297). Gofman's work led to a worldwide reevaluation of both medical radiation (and the elimination of those shoe-store machines) and of the way nuclear power plants were constructed and operated. Today he is still considered one of the leading experts on the effect of radiation on the human body.

The Relationship Between Radiation and Cancer

Here's what Dr. Gofman says to anybody who claims that nuclear medicine procedures (such as SPECT scans) are "safe":

"In the mainstream medical literature are quite a number of epidemiological studies showing that even minimal doses of ionizing radiation induce extra cases of cancer" (emphasis added).

In a 1995 paper on low-dose radiation, Dr. Gofman pointed out that it only takes a single electron/photon-bullet (to use my analogy above), hitting the wrong part of a single cell, to cause cancer. Here's how he summarized that paper on low-dose radiation, with five well-documented points that reflect the current state of knowledge:

"Point One: The radiation dose from x-rays, gamma rays, and beta particles is delivered by high-speed electrons, traveling through human cells and creating primary ionization tracks. Whenever there is any radiation dose, it means some cells and cell-nuclei are being traversed by electron-tracks. There are about 600 million typical cells in 1 cubic centimeter.

"Point Two: Every track --- without any help from another track --- has a chance of inflicting a genetic injury if the track traverses a cell-nucleus.

"Point Three: There are no fractional electrons. This means that the lowest 'dose' of radiation that a cell-nucleus can experience is one electron-track.

"Point Four: There is solid evidence that extra human cancer does occur from radiation doses which deliver just one or a few tracks per cell-nucleus, on the average.

"Point Five: Thus we know that there is no dose or dose-rate low enough to guarantee perfect repair of every carcinogenic injury induced by radiation. Some carcinogenic injuries are just unrepaired, or misrepaired...

"Conclusion: It is factually wrong to believe or to claim that no harm has ever been proven from very low-dose radiation. On the contrary. Existing human evidence shows cancer-induction by radiation at and near the lowest possible dose and dose-rate with respect to cell nuclei. By any reasonable standard of scientific proof, such evidence demonstrates that there is no safe dose or dose-rate below which dangers disappear. No threshold-dose. Serious, lethal effects from minimal radiation doses are not 'hypothetical,' 'just theoretical,' or 'imaginary.' They are real."

Agreeing with the dangers of radiation to radiosensitive children, the National Academy of Neuropsychology published an article in 1991 suggesting nuclear medicine should be limited exclusively to pure research (which is not done in a doctor's office), with appropriate informed consent about the dangers, safeguards and follow-up, no cost to the client, committee overview, etc. (Heaton,T.B. & Bigler, E.D. 1991. Neuroimaging techniques in neuropsychological research. Bulletin of the National Academy of Neuropsychology, 9, 14.)

When I broke my back skydiving in 1971, I had a series of x-rays. Each one was a very quick burst of radiation, and each one increased my lifetime risk of developing cancer. Those x-rays were considered "safe" from a medical point of view, even though every medical expert acknowledges they can cause cancer, but they were "safe enough" because the risk of not knowing how badly my spine was injured was outweighed by the small probability the x-rays would cause cancer. This is referred to as the "risk-benefit ratio" and is how the government determines what they will call a "safe" level of exposure to radiation or other toxins.

The shoe-store machine, however, because it delivered a more prolonged dose of radiation to me (instead of a "picture" that flashed me with X-rays for a thousandth of a second, it was a continuous "movie" flow of X-rays), was dramatically more destructive to my DNA, so much so that after Dr. Gofman's research was published in the 1960s nobody could justify keeping the machines in the shoe stores any longer.

Neither of those radiation exposures, however, fired "bullets" of radiation at the most radiation-sensitive and cancer-reactive parts of my body - my brain, testicles, and much of my endocrine system (thyroid, etc.).

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SPECT Scans for Diagnosing ADHD

But with a SPECT scan, a child is injected with a radioactive material directly into his bloodstream. Its radiation-emitting particles are carried to every nook and cranny of his body. They flow into and irridadiate his developing testicles or her young ovaries and the eggs in them that will someday become children. The radiation flows with the blood into the thyroid, the uterus, pre-developing breast tissue, the adrenals, the pituitary, and even the bone marrow. Although most SPECT scannerss are only positioned to look for the "single photons" that are evoked by the detector when particles flash out of deep brain tissue, through the dura mater, through the bone of the skull, and the skin of the scalp to hit the SPECT detector, the entire body is filled with radiation.

If the SPECT scanner were put on the stomach, it would find radiation there; on the genitals, radiation there; on the feet, radiation there. "Bullets" are going off throughout the entire body - including in the child's most radiosensitive organs such as developing breast, ovarian, testicular, uterine, and thyroid tissues. And the "hit" isn't only for a fraction of a second, like it would be with an X-ray: the radioactive agent injected with a SPECT scan decays slowly, and is still detectible in the bloodstream for days after injection. (And each time one of the unstable radioactive atoms of the SPECT agent decays to something that's no longer radioactive, it emits "bullet" particles in the process, those hitting and tracking through the nearby tissues of the body at the time of breakdown.)

Lately there has been a lot of talk about the use of SPECT scans to diagnose ADHD. Of particular concern is that some physicians are using this procedure, whose risk-benefit ratio is considered acceptable for things like brain injury after a car accident or stroke (the main use for SPECT scans), on children. Children are far more susceptible to radiation-induced cancer than are adults, in part because radiation damage accumulates over time and cancers from radiation usually pop up decades after the initial exposure, and in part because their tissues are still developing and growing.

In 1997, at an ADHD conference in Israel, I had coffee with the National Institute of Health's Dr. Alan Zametkin, who had done PET scan studies (which use lower-doses of radiation) on the brains of adults with ADHD to look for differences, and whose work had recently appeared on the cover of the Journal of the American Medical Association's magazine. I asked Dr. Zametkin about the use of SPECT scans on children, and he told me flatly that he considered it both wrong and dangerous for the children.

While his PET scan studies had injected radioactive isotopes into the veins of their research subjects, they'd used a multi-million-dollar ultra-sensitive PET scanner to look for the action of the isotopes, meaning less radiation was needed to be injected than with the SPECT scan machines, which are affordable for an emergency room or doctor's office but less sensitive. (A PET scanner fills a room and is normally only found in a hospital or research facility: portable SPECT scan machines are available for emergency clinic and field use at much lower prices.) And Zametkin's studies had been done on consenting adults (not children) who were fully informed of the risks they were taking in receiving a full-body dose of decaying radiation, and who had not paid Dr. Zametkin to be in the study but were instead monitored for ill-effects from the radiation and offered other compensations.

Dr. Zametkin's perspective represents the mainstream scientific view of using nuclear medicine, particularly with children, for anything other than pure research or life-threatening illness or injury. This is probably why when Daniel Amen told Dr. Zametkin that he intended to use SPECT scans on children, Dr. Zametkin reacted negatively. To quote Dr. Amen, "He gave me an angry look and said that the imaging work was just for research: It wasn't ready for clinical use, and we shouldn't use it until much more was known about it." (Healing ADD, Amen, 2001)

Safer Brain Imaging Techniques

Of course, much is known about the effects of SPECT and PET scans. They require injecting the entire body with a continual "spray of bullets" that decay over time. Their radiation exposure doesn't last a thousandth of a second, like an x-ray, or even a few seconds like a fluoroscope: it lasts for hours, days, and traces remain for weeks. Everywhere in the body. With every single particle emitting radiation as it decays, and that radiation penetrating millions of cells on its way out of the body. While it is possible to say that "no studies have shown that SPECT scans or the radiation levels used in them cause cancer," it is a bit disingenuous: the only reason one could say that is that no such studies have ever been done. Actually, they're not necessary: there is no such thing as "purely safe" radiation, just "risk-acceptable safe" radiation in the context of the need for the procedure.

There are techniques for imaging the brain that do not require injecting people with radioactive isotopes. The best-known and most widely used is the QEEG, which measures electrical activity at over a hundred different points on the scalp and then uses a computer to create a mapped image of brain activity. These have become quite sophisticated, and involve no danger whatsoever because they're totally passive, "reading" the brain's own electrical activity instead of injecting something into the body which is then measured as it shoots back out of the body.

So the next time somebody suggests a SPECT scan for you or your child, imagine yourself standing in that hotel window, looking down at shooter on the lawn. You're a cell in your body, and the shooter is just one of the millions of particles of radioactive substance about to be injected into your or your child's vein prior to the SPECT scan.

And don't forget to duck.

About the author: Thom Hartmann is an award-winning, bestselling author of books on ADHD in children and adults, international lecturer, teacher, radio talk show host, and psychotherapist.

Read also: Study Raises Hopes for ADHD Medical Test.

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Stewart 1970. Alice M. Stewart + George W. Kneale, "Radiation Dose Effects in Relation to Obstetric X-Rays and Childhood Cancers," Lancet 1: 1185-1188. 1970.
UNSCEAR 1993. United Nations Scientific Committee on the Effects of Atomic Radiation. Sources and Effects of Ionizing Radiation: UNSCEAR 1993 Report to the General Assembly, with Scientific Annexes. 922 pages. No index. ISBN 92-1-142200-0. 1993. Committee for Nuclear Responsibility, Inc. Post Office Box 421993, San Francisco, CA 94142, USA.
 

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If Dickens had written a book about Hollywood, he could not have penned a childhood more desperate yet inspirational than Patty Duke's. Born Anna Marie Duke 54 years ago, Patty was systematically alienated and virtually kidnapped from her troubled mother and alcoholic father by talent managers Ethel and John Ross at an age when most children are learning their ABC's. In the hands of the Rosses, she endured unabated abuse for more than a decade. Her startling acting talent was at once a key to escaping the sorrow of her life and a doorway to a mental affliction that very nearly took her life.

When she was 7, Duke was already smiling in commercials and small television parts. Next, her young career led her to Broadway and later to a role as Helen Keller in a stage version of The Miracle Worker. She starred in a screen adaptation of the play, which garnered a frenzy of praise and an Oscar, and she was later offered her own TV series. The Patty Duke Show's hugely popular three-year run in the mid-1960s clinched her status as a teen icon. Yet Anna was never able to find joy in her success. She would endure a long struggle with manic depression and medicinal misdiagnoses before she would find the girl she was forced to pronounce "dead" and learn to live her life without fear. In a Psychology Today exclusive, she discusses some key moments on the path to her well-being.

I was 9 years old and sitting alone in the back of a cab as it rumbled over New York City's 59th Street bridge. No one was able to come with me that day. So there I was, a tough little actor handling a Manhattan audition on my own. I watched the East River roll into the Atlantic, then I noticed the driver who was watching me curiously. My feet began tapping and then shaking, and slowly, my chest grew tight and I couldn't get enough air in my lungs. I tried to disguise the little screams I made as throat clearings, but the noises began to rattle the driver. I knew a panic attack was coming on, but I had to hold on, get to the studio and get through the audition. Still, if I kept riding in that car I was certain that I was going to die. The black water was just a few hundred feet below.

"Stop!" I screamed at him. "Stop right here, please! I have to get out!"

"Young miss, I can't stop here."

"Stop!"

I must have looked like I meant it, because we squealed to a halt in the middle of traffic. I got out and began to run, then sprint. I ran the entire length of the bridge and kept going. Death would never catch me as long as my small legs kept propelling me forward. The anxiety, mania and depression that would mark much of my life was just beginning.

Ethel Ross, my agent and substitute parent, was combing my hair one day a few years earlier, wrestling furiously with the tangles and knots that formed on my head, when she said, "Anna Marie Duke, Anna Marie. It's not perky enough." She forced her way through a particularly tough hair bramble as I winced. "OK, we've finally decided," she declared "You are gonna change your name. Anna Marie is dead. You are Patty, now."

I was Patty Duke. Motherless, fatherless, scared to death and determined to act my way out of sadness but feeling as if I was already going crazy.

Although I don't think that my bipolar disorder fully manifested itself until I was about 17, I had struggles with anxiety and depression throughout my childhood. I have to wonder, as I look at old films of mine when I was a child, where I got that shimmering, supernatural energy. It seems to me that it came from three things: mania, fear of the Rosses and talent. Somehow I had to, as a child o f 8, understand why my mother, to whom I was attached at the hip, had abandoned me. It may be that part of her knew that the Rosses could better manage my career. And maybe it was partly due to her depression. All I knew was that I barely saw my mother and that Ethel discouraged even the smallest contact with her.

Because I wasn't able to express anger or hurt or rage, I began a very unhappy and decades' long pursuit of denial just to impress those around me. It's odd and thoroughly displeasing to recall, but I do think that my unnatural vivacity in my very early movies was largely because acting was the only outlet I had for exorcising my emotions.

While working on The Miracle Workerplay, the movie and later, The Patty Duke Show, I began to experience the first episodes of mania and depression. Of course, a specific diagnosis was unavailable then, so each condition was either ignored, scoffed at by the Rosses or medicated by them with impressive amounts of stelazine or thorazine. The Rosses seemed to have an inexhaustible amount of drugs. When I needed to be ratcheted down during a crying spell at night, the drugs were always there. I understand now, of course, that both stelazine and thorazine are antipsychotic medications, worthless in the treatment of manic depression. In fact, they may well have made my condition worse. I slept long, but never well.

The premise of The Patty Duke Show was a direct result of a few days spent with TV writer Sydney Sheldon, and if I'd had enough wit at the time, the irony would have deafened me. ABC wanted to strike while my stardom iron was still hot and produce a series, but neither I nor Sidney nor the network had an idea as to where to begin. After several talks, Sidney, jokingly but with some conviction, pronounced me "schizoid." He then produced a screenplay in which I was to play two identical 16-year-old cousins: the plucky, irascible, chatty Patty and the quiet, cerebral and thoroughly understated Cathy. The uniqueness of watching me act out a modestly bipolar pair of cousins when I was just beginning to suspect the nature of the actual illness swimming below the surface must have given the show some zing, because it became a huge hit. It ran for 104 episodes, though the Rosses forbade me from watching a single one...lest I develop a big head.

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The disease came over me slowly in my late teens, so slowly and with such duration of both manic and depressive states that it was tough to tell just how sick I had become. It was all the more difficult because I would very often feel just fine and rejoice in the success I had. I was made to feel coveted and invulnerable, despite the fact that I came home to the Rosses who treated me as a thankless, bumbling ingrate. By 1965, I was able to see the awfulness of their home and their lives, so I found the courage to say that I would never set foot in their house again. I moved to Los Angeles to shoot the third season of The Patty Duke Showand started my tenth year as an actor. I was 18.

There were successes thereafter, and plenty of failures, but my struggle always concerned my bipolar disorder more than the eccentricities and paper-thinness of Hollywood or the challenges of family life. I married, I divorced, I drank and I smoked like a munitions factory. I cried for days at a time in my twenties and worried the hell out of those close to me.

One day during that period, I got into my car and thought I heard on the radio that there had been a coup at the White House. I learned the number of intruders and the plan they had concocted to overthrow the government. Then I became convinced that the only person who could address and remedy this amazing situation was me.

I raced home, threw a bag together, called the airport, booked a red-eye flight to Washington and arrived at Dulles Airport just before dawn. When I got to my hotel, I immediately called the White House and actually spoke to people there. All things considered, they were wonderful. They said that I had misinterpreted the events of the day, and as I spoke to them I began to feel the mania drain from me. In a very, very real sense I awoke in a strange hotel room, 3,000 miles from home and had to pick up the pieces of my manic episode. That was just one of the dangers of the disease: to wake up and be somewhere else, with someone else, even married to someone else.

When I was manic, I owned the world. There were no consequences for any of my actions. It was normal to be out all night, waking up hours later next to someone I didn't know. While it was thrilling, there were overtones of guilt (I'm Irish, of course). I thought I knew what you were going to say before you said it. I was privy to flights of fancy that the rest of the world could scarcely contemplate.

Through all of the hospitalizations (and there were several) and the years of psychoanalysis, the term manic-depressive was never used to describe me. I have to take some of the credit (or blame) for that, because I was also a master at disguising and defending my emotions. When the bipolar swung to the sad side, I was accomplished at using lengthy spells of crying to hide what was bothering me. At the psychiatrist's office, I would sob for the entire 45 minutes. In retrospect, I used it as a disguise; it kept me from discussing the loss of my childhood and the terror of each new day.

I'd cry, it seemed, for years at a time. When you do this, you don't need to say or do anything else. A therapist would simply ask, "What are you feeling?" and I'd sit and cry for 45 minutes. But I would work out excuses to miss therapy, and some of these plans took days to concoct.

In 1982 I was filming an episode of the series It Takes Twowhen my voice gave out. I was taken to a doctor who gave me a shot of cortisone, which is a fairly innocuous treatment for most people, with the exception of manic-depressives. For the next week I battled an all too familiar anxiety. I could barely get out of the bathroom. My voice cadence changed, my speech began to race, and I was virtually incomprehensible to everyone around me. I literally vibrated.

I lost a noticeable amount of weight in just a few days and was finally sent to a psychiatrist, who told me he suspected I had manic-depressive disorder and that he would like to give me lithium. I was amazed that someone actually had a different solution that might help.

Lithium saved my life. After just a few weeks on the drug, death-based thoughts were no longer the first I had when I got up and the last when I went to bed. The nightmare that had spanned 30 years was over. I'm not a Stepford wife; I still feel the exultation and sadness that any person feels, I'm just not required to feel them 10 times as long or as intensively as I used to.

I still struggle with depression, but it is different and not as dramatic. I don't take to my bed and cry for days. The world, and myself, just gets very quiet. That's the time for therapy, counseling or a job.

My only regret is the time lost in a haze of despair. Almost at the exact moment I began to feel better, I entered a demographic in show business whose members are hard-pressed for work. I've never felt more capable of performing well, of taking on roles with every ounce of enthusiasm and ability, only to find that there are precious few roles for a woman in her fifties. The joke in our house was "I finally got my head together and my ass fell off."

I can be, and often am, sad, but not bitter. When my daughter died in an automobile accident last year, I was forced to take a long look at bitterness and regret and sadness. The process of missing her and rebuilding myself will continue for years, but I know that the children, friends and love I have will plant seeds and patch holes I didn't even know were there. I worry more about the people who struggle with sadness alone, and there are millions of them.

Just the other day I was walking through a parking lot and heard a woman yell, "Is that Patty?" I saw how she moved, how her eyes danced and I listened to her frenzied vocabulary. She was bipolar. I spoke with this woman for a few minutes, and she told me of her struggles with the disease, that she was having a tough time of it lately but that she appreciated my help in championing manic depression. The implication was that if I could make it, she could. Damn straight.

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Journal editorial suggests the newer antidepressant drugs are overprescribed

There's no doubt the newer generation of antidepressants, which include Prozac and , have revolutionized the way depression is treated.

Was that change for the better?

No, says Dr. Giovanni Fava, a professor of clinical psychology at the University of Bologna in Italy and the department of psychiatry at the State University of New York at Buffalo.

In an editorial in the current issue of the journal Psychotherapy and Psychosomatics, Fava argues that drug company propaganda, rather than need or clinical evidence, is responsible for the soaring popularity of these newer antidepressant medications.

Other doctors and, not surprisingly, the pharmaceutical industry disagree with Fava's position.

Almost 10 percent of the U.S. population suffers from depression, according to the National Institute for Mental Health, though most don't seek treatment for the condition.

During the 1990s, Fava says, doctors started prescribing antidepressants for long-term use because several studies suggested a depression relapse was likely if an antidepressant drug was discontinued.

However, in his editorial, Fava says the evidence for long-term antidepressant use really isn't clear and other research has shown the duration of treatment -- whether three months or three years -- doesn't really matter because the drugs are most effective in the acute phase of depression. He says that despite the lack of evidence, these medications were touted in journal articles, symposia and practice guidelines.

He also contends the effectiveness of these antidepressant drugs has been overemphasized, and they're no more effective than older tricyclic medications; they just have fewer side effects. And, he adds, research has shown antidepressants don't actually change the course of depression; they just speed the recovery.

Fava also says that because the drugs have fewer side effects and are more tolerable, more patients with mild depression are being put on medications they may not need.

Fava says the effects of withdrawal from these antidepressant drugs are downplayed, and non-drug options such as cognitive behavioral therapy get short shrift in research literature.

Fava does, however, believe that antidepressants have a place in treatment. For patients who need them, he advocates a careful assessment after three months of antidepressant therapy, and then tapering the drug therapy down until the patient is off the medication. At the same time, he recommends cognitive behavioral therapy, lifestyle changes and more traditional well-being therapy.

After a patient has been off antidepressants for a month, Fava advises another assessment to make sure the depressive symptoms haven't returned.

Dr. Norman Sussman, a psychiatrist at New York University Medical School who has also studied the effects of antidepressants, says Fava raises several issues in his editorial that have been debated for years. The bottom line, he says, is that antidepressants work.

"The literature indicates they're effective, and I have seen them work," Sussman says.

He adds some of the clinical trials Fava uses to make his point were more rigidly constructed than a real-life treatment plan would be. Sussman says there's always an element of trial-and-error to antidepressant therapy to find what works best with the least side effects. In clinical trials, he says, researchers can't switch medications mid-trial, but in the real world doctors can adjust the amount of medication given.

There have been several studies where some patients were switched to placebo drugs after three months of antidepressant therapy, and that patients who stayed on the drugs were less likely to relapse into depression, Sussman says.

He acknowledges the newer medications probably aren't any more effective than the older medications in most cases. "The real breakthrough was in the tolerability," he says.

Before the newer drugs were introduced, antidepressants had a lot of unpleasant side effects. Patients had to be started on a low dose, which was gradually increased over a month or two before they were getting the full dose to minimize the unpleasant side effects, Sussman says.

Sussman does agree with Fava that pharmaceutical companies only present their best data and may sometimes overstate their products' efficacy. However, he says, that doesn't change the fact that antidepressants work.

Jeff Trewhitt, the national spokesman for the Pharmaceutical Research and Manufacturers of America, says he doesn't believe drug companies are guilty of propaganda, and explains that the industry is introducing new guidelines to ensure that firms avoid any appearance of impropriety.

"In the vast majority of cases, the relationship between sales representatives and physicians is appropriate and helpful," Trewhitt says. He adds the new guidelines forbid gifts of theater or sporting event tickets, and travel to information seminars can only be reimbursed if a physician is speaking at the conference.

As to whether the newer antidepressants are being prescribed appropriately, Trewhitt says, "Based on the anecdotal evidence, it seems clear to us in the vast majority of cases that physicians are using these antidepressant medications because they are effective, and in many cases have fewer side effects than many of the older drugs."

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We all feel moments of gloom or exhilaration on occasion. But few of us truly understand how far off-key the melodies of mood can drift. Here, a leading psychiatrist eloquently recounts two real-life tales of mania and depression--and shows how these disorders are indeed moods apart from our everyday experience.

TRY FOR A MOMENT TO IMAGINE a personal world drained of emotion, a world where perspective disappears. Where strangers, friends, and lovers are all held in similar affection, where the events of the day have no obvious priority. There is no guide to deciding which task is most important, which dress to wear, what food to eat. Life is without meaning or motivation.

This colorless state of being is exactly what happens to some victims of melancholic depression, one of the most severe mood disorders. Depression--and its polar opposite, mania--are more than illnesses in the everyday sense of the term. They cannot be understood merely as an aberrant biology that has invaded the brain; for by disturbing the brain the illnesses, enter and disturb the person--the feelings, behaviors, and beliefs that uniquely identify the individual self. These afflictions invade and change the very core of our being. And the chances are overwhelming that most of us, during our lifetime, will come face to face with mania or depression, seeing them in ourselves or in somebody close to us. It's estimated that in the United States 12 to 15 percent of women and eight to 10 percent of men will struggle with a serious mood disorder during their lifetime.

While in everyday speech the words mood and emotion are often used interchangeably, it is important to distinguish them. Emotions are usually transient--they constantly respond to our thoughts, activities, and social situations throughout the day. Moods, in contrast, are consistent extensions of emotion over time, sometimes lasting for hours, days, or even months in the case of some forms of depression. Our moods color our experiences and powerfully influence the way we interact. But moods can go wrong. And when they do, they significantly alter our normal behavior, changing the way we relate to the world and even our perception of who we are.

CLAIRE'S STORY. Claire Dubois was such a victim. It was the 1970s, when I was professor of psychiatry at Dartmouth Medical School. Elliot Parker, Claire's husband, had telephoned the hospital desperately worried about his wife, who he suspected had tried to kill herself with an overdose of sleeping pills. The family lived in Montreal, but were in Maine for the Christmas holidays. I agreed to see them that afternoon.

Before me was a handsome woman approaching 50 years of age. She sat mute, eyes cast down, holding her husband's hand without apparent anxiety or even interest in what was going on. In response to my questioning she said very quietly that it was not her intention to kill herself but merely to sleep. She could not cope with daily existence. There was nothing to look forward to and she felt of no value to her family. And she could no longer concentrate sufficiently to read, which had been her greatest passion.

Claire was describing what psychiatrists call anhedonia. The word literally means "the absence of pleasure," but in its most severe form anhedonia becomes an absence of feeling, a blunting of emotion so profound that life itself loses meaning. This lack of feeling is most frequently present in melancholia, which lies on a continuum with depression, extending the illness to its most disabling and frightening form. It is a depression that has taken root and grown independent, distorting and choking the feeling of being alive.

SLIP SLIDING AWAY. In Claire's mind and in Elliot's, the whole thing began after an automobile accident the winter before. On a snowy evening, while on her way to pick up her children from choir practice, Claire's car had slid off the road and down an embankment. The injuries she sustained were miraculously few but included a concussion from her head hitting the windshield. Despite this good fortune, she began to experience headaches in the weeks following the accident. Her sleep became fragmented, and with this insomnia came increasing fatigue. Eating held little attraction. She was irritable and inattentive, even to her children. By the spring, Claire was complaining of dizzy spells. She was seen by the best specialists in Montreal, but no explanation could be found. In the words of the family doctor, Claire was "a diagnostic puzzle."

The summer months, when she was alone in Maine with her children, brought minor improvement, but with the onset of winter the disabling fatigue and insomnia returned. Claire withdrew to the world of books, turning to Virginia Woolf's novel The Wave, for which she had a particular affection. But as the shroud of melancholy fell upon her, she found sustaining her attention increasingly difficult, and a critical moment arrived when Woolf's woven prose could no longer occupy Claire's befuddled mind. Deprived of her last refuge, Claire had only one thought, drawn possibly from her identification with Woolf's own suicide: that the next chapter in Claire's life should be to fall asleep forever. This stream of thought, almost incomprehensible to those who have never experienced the dark vortex of melancholy, is what preoccupied Claire in the hours before she took the sleeping pills that brought her to my attention.

Why should sliding off an icy road have precipitated Claire into this black void of despair? Many things can trigger depression. In a sense it is the common cold of emotional life. In fact, depression can literally follow in the wake of the flu. Just about any trauma or debilitating illness, especially if it lasts a long time and limits physical activity and social interaction, increases our vulnerability to depression. But the roots of serious depression grow slowly over many years and are usually shaped by numerous separate events, which combine in a way unique to the individual. In some, a predisposing shyness is amplified and shaped by adverse circumstance, such as childhood neglect, trauma, or physical illness. In those who experience manic depression, there are also genetic factors that determine the shape and course of the mood disturbance. But even there the environment plays a major role in determining the timing and frequency of illness. So the only way to understand what kindles depression is to know the life story behind it.

THE TRIP THAT WASN'T. Claire Dubois was born in Paris. Her father was much older than her mother and died of a heart attack shortly after Claire's birth. Her mother remarried when Claire was eight, but drank heavily and was in and out of hospital with various ailments until she died in her late forties. By necessity a solitary child, Claire discovered literature at an early age. Books offered a fairy-tale adaptation to the reality of daily life. Indeed, one of her fondest memories of adolescence was of lying on the floor of her stepfather's study, sipping wine and reading Madame Bovary. The other good thing about adolescence was Paris. Within walking distance were all the bookstores and cafes an aspiring young woman of letters could desire. These few blocks of the city became Claire's personal world.

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Just before the second World War, Claire left Paris to attend McGill University in Montreal. There, she spent the war years consuming every book she could lay her hands on, and after college she became a freelance editor. When the war ended, she returned to Paris at the invitation of a young man she had met in Canada. He proposed marriage, and Claire accepted. Her new husband offered her a sophisticated life among the city's intellectual elite, but after only 10 months he declared that he wanted a separation. Claire never fathomed the reason for his decision; she assumed he had discovered some deep flaw in her that he would not reveal. After months of turmoil she agreed to a divorce and resumed to Montreal to live with her stepsister.

Much saddened by her experience and considering herself a failure, she entered psychoanalysis and her life stabilized. Then, at age 33, Claire married Elliot Parker, a wealthy business associate of her brother-in-law's, and soon the couple had two daughters.

Claire initially valued the marriage. The sadness of her earlier years did not return, although at times she drank rather heavily. With her daughters now growing rapidly, Claire proposed that the family live in Paris for a year. She eagerly planned the year in every detail. "The children were signed up for school. I had rented houses and cars; we had paid deposits," she recalled. "Then, one month before it was to begin, Elliot came home to say that money was tight and it couldn't be done.

"I remember crying for three days. I felt angry but totally impotent. I had no allowance, no money of my own, and absolutely no flexibility." Four months later, Claire slid off the road and into the snowbank.

As Claire and Elliot and I explored her life story together, it was clear to all that the event that kindled her melancholia was not her automobile accident but the devastating disappointment of the canceled return to France. That was where her energy and emotional investment had been placed. She was grieving the loss of the dream of introducing her adolescent daughters to what she herself had loved as an adolescent: the streets and bookshops of Paris, where she had crafted a life for herself out of her lonely childhood.

Elliot Parker loved his wife, but he had not truly understood the emotional trauma of canceling the year in Paris. And it was not Claire's nature to explain how important it was to her or to request an explanation of Elliot's decision. After all, she had never received one from her first husband when he left her. The accident itself further obscured the true nature of her disability: Her restlessness and fatigue were taken as the residue of a nasty physical encounter.

THE LONG ROAD TO RECOVERY. Those bleak midwinter days marked the nadir of Claire's melancholia. Recovery required a hospital stay, which Claire welcomed, and she soon missed her daughters--a reassuring sign that the anhedonia was cracking. What she found difficult was our insistence that she follow a routine--getting out of bed, showering, eating breakfast with others. These simple things we do everyday were for Claire giant steps, comparable to walking on the moon. But a regular routine and social interaction are essential emotional exercises in any recovery program--calisthenics for the emotional brain. Toward the third week of her hospital stay, as the combination of behavioral treatment and antidepressant drugs took hold, Claire's emotional self showed signs of reawakening.

It was not difficult to imagine how her mother's whirlwind social life and repeated illnesses, plus the early death of her father, had made Claire's young life a chaotic experience, depriving her of the stable attachments from which most of us securely explore the world. She longed for intimacy and considered her isolation a mark of her unworthiness. Such patterns of thinking, common in those who suffer depression, can be shed through psychotherapy, an essential part of the recovery from any depression. Claire and I worked on reorganizing her thinking while she was still in the hospital, and we continued after she returned to Montreal. She was committed to change; each week she employed her commuting time to review the tape of our therapy session. All together, Claire and I worked intensively together for almost two years. It was not all smooth sailing. On more than one occasion, in the face of uncertainty, hopelessness returned, and sometimes Claire succumbed to the anesthetic beckoning of too much wine. But slowly she was able to put aside old patterns of behavior. While it is not the case for all, for Claire Dubois the experience of depression was ultimately one of renewal.

One reason that we do not diagnose depression earlier is that--as in Claire's case--the right questions are not asked. Unfortunately, this state of ignorance is often present as well in the lives of those who experience mania, the colorful and deadly cousin of melancholia.

STEPHAN'S TALE. "In the early stages of mania I feel good--about the world and everybody in it. There's a sense that my life will be full and exciting." Stephan Szabo, elbows on the bar, leaned closer as voices rose from the crush of people around us. We had met years earlier in medical school, and on one of my visits to London he agreed to a few beers at the Lamb and Flag, an old pub in the Covent Garden district. Despite the jostle of the evening crowd, Stephan seemed unperturbed. He was warming to his topic, one he knew well: his experience with manic depression.

"It's a very infectious thing. We all appreciate somebody who's positive and upbeat. Others respond to the energy. People I don't know very well--even people I don't know at all--seem happy around me.

"But the most extraordinary thing is how my thinking changes. Usually I think about what I'm doing with the future in mind; I'm almost a worrier. But in the early manic periods everything focuses upon the present. Suddenly I have the confidence that I can do what I had set out to do. People give me compliments about my insight, my vision. I fit the stereotype of the successful, intelligent male. It's a feeling that can last for days, sometimes weeks, and it's wonderful."

A TERRIBLE TORNADO. I felt fortunate Stephan was willing to talk openly about his experience. A Hungarian refugee, Stephan had begun his medical studies in Budapest before the Russian occupation of 1956, and in London we had studied anatomy together. He was a wry political commentator, an extraordinary chess player, an avowed optimist, and a good friend to all. Everything Stephan did was energetic and purposeful.

Then two years after graduation came his first episode of mania, and during the depression that followed he tried to hang himself. In recovery, Stephan had been quick to blame two unfortunate circumstances: He had been denied entry to the Oxford University graduate program and, worse, his father had committed suicide. Insisting that he was not ill, Stephan refused any long-term treatment and over the next decade suffered several further bouts of illness. When it came to describing mania from the inside, Stephan knew what he was talking about.

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He lowered his voice. "As time rolls on, my head speeds up; ideas move so fast they stumble over each other. I begin to think of myself as having special insight, understanding things that others do not. I recognize now that these are warning signs. But typically, at this stage people still seem to enjoy listening to me, as if I have some special wisdom.

"Then at some point I start to believe that because I feel special, maybe I am special. I have never actually thought I was God, but a prophet, yes, that has occurred to me. Later--probably as I cross into psychosis--I sense that I am losing my own will, that others are trying to control me. It's at this stage that I first feel twinges of fear. I become suspicious; there's a vague feeling that I am the victim of some outside force. After that everything becomes a terrifying, confusing slide that is impossible to describe. It's a crescendo--a terrible tornado--that I wish never to experience again."

I asked at what point in the process he considered himself ill.

Stephan smiled. "It's a tough question to answer. I think the `illness' is there, in muted form, in some of the most successful among us--those leaders and captains of industry who sleep only four hours a night. My father was like that, and so was I in medical school. It's a feeling that you have the ability to live life fully in the present. What's different about mania is that it goes higher until it blows away your judgment. So it is not simple to determine when I go from being normal to being abnormal. Indeed, I'm not sure I know what a `normal' mood is."

EXHILARATION AND DANGER

I believe there is much truth in Stephan's musing. The experience of hypomania--of early mania--is described by many as comparable to the exhilaration of falling in love. When the extraordinary energy and self-confidence of the condition are harnessed with a natural talent--for leadership or the arts--such states can become the engine of achievement. Cromwell, Napoleon, Lincoln, and Churchill, to name a few, appear to have experienced periods of hypomania and discovered the ability to lead in times when lesser mortals failed. And many artists--Poe, Byron, Van Gogh, Schumann--had periods of hypomania in which they were extraordinarily productive. Handel, for example, is said to have written The Messiah in just three weeks, during an episode of exhilaration and inspiration.

But where early mania may be exciting, mania in full flower is confusing and dangerous, seeding violence and even self-destruction. In the United States, a suicide occurs every 20 minutes--some 30,000 people a year. Probably two-thirds are depressed at the time, and of those half will have suffered manic-depression. Indeed, it's been estimated that of every 100 people who suffer manic-depressive illness, at least 15 will eventually take their own lives--a sobering reminder that mood disorders are comparable to many other serious diseases in shortening the life span.

The crush of revelers in the Lamb and Flag had diminished. Stephan had changed little with the years. True, he had less hair, but there before me was the same nodding head, the long neck and square shoulders, the dissecting intellect. Stephan had been lucky. Over the past decade, since he had decided to accept his manic depression as an illness--something he had to control lest it control him--he had done well. Lithium Carbonate, a mood stabilizer, had smoothed his path, reducing the malignant manias to manageable form. The rest he had achieved for himself.

While we may aspire to the vivacity of early mania, at the other end of the continuum depression is still commonly considered evidence of failure and a lack of moral fiber. This will not change until we can speak openly about these illnesses and recognize them for what they are: human suffering driven by dysregulation of the emotional brain.

I reflected this to Stephan. He readily agreed. "Look at it this way," he said as we got up from the bar, "things are improving. Twenty years ago neither of us would have dreamed about meeting in a public place to discuss these things. People are interested now because they recognize that mood swings, in one form or another, touch everybody every day. Times really are changing."

I smiled to myself. Here was the Stephan I remembered. He was still in the saddle, still playing chess, and still optimistic. It was a good feeling.

THE MEANING OF MOODS

During a recent interview, I was asked what hope I could give those who suffer the "blues." "In the future," my interviewer asked, "will antidepressants eliminate sadness, just as fluoride has eradicated cavities in our teeth?" The answer is no--antidepressants are not mood elevators in those without depression--but the question is provocative for its cultural framing. In many countries, the pursuit of pleasure has become the socially accepted norm.

Behavioral evolutionists would argue that our increasing intolerance of negative moods perverts the function of emotion. Transient episodes of anxiety, sadness, or elation are part of normal experience, barometers of experience that have been essential to our successful evolution. Emotion is an instrument of social self-correction--when we are happy or sad, it has meaning. Seeking ways to blot out variation in mood is equivalent to the airline pilot ignoring his navigational devices.

Perhaps mania and melancholia endure because they have had survival value. The generative energy of hypomania, it can be argued, is good for the individual and social groups. And perhaps depression is the built-in braking system required to return the behavioral pendulum to its set point after a period of acceleration. Evolutionists have also suggested that depression helps maintain a stable social hierarchy. After the fight for dominance is over, the vanquished withdraws, no longer challenging the leader's authority. Such withdrawal provides a respite for recovery and an opportunity to consider alternatives to further bruising battles.

Thus the swings that mark mania and melancholia are musical variations upon a winning theme, variations that play easily but with a tendency to become progressively off-key. For a vulnerable few the adaptive behaviors of social engagement and withdrawal unravel under stress into mania and melancholic depression. These disorders are maladaptive for the individuals who suffer them, but their roots draw upon the same genetic reservoir that has enabled us to be successful social animals.

Several research groups are now searching for genes that increase vulnerability to manic depression or recurrent depression. Will neuroscience and genetics bring wisdom to our understanding of the disorders of mood and spur new treatments for those who suffer these painful afflictions? Or will some members of our society harness genetic insights to sharpen discrimination and drain compassion, to deprive and stigmatize? We must remain vigilant, but I am confident that humanity will prevail, for all of us have been touched by these disorders of the emotional self. Mania and melancholia are illnesses with a uniquely human face.

From A Mood Apart by Peter C. Whybrow, M.D. Copyright 1997 by Peter C. Whybrow. Reprinted by permission of BasicBooks, a division of HarperCollins Publishers, Inc.

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