ECT in action: 'It was my magic wand' ECT in action: 'It made my mania worse' Using electroconvulsive therapy for depression remains controversial. Dr Max Pemberton examines the evidence Depression kills. Suicide in the UK constitutes nearly one per cent of deaths from all causes every year.   Depression can kill. Is ECT the answer? It is the single biggest killer of young men after road traffic accidents, and the 2001 Confidential Enquiry into Maternal Deaths found that suicide was the leading cause of maternal mortality in the UK. Depression also destroys lives insidiously, dismantling them piece by piece until little remains. With around a quarter of us experiencing depression in our lifetimes, and between five and 10 per cent suffering from it at any one time, it represents a significant public health issue. But depression is treatable. The development of talking and pharmaceutical therapies such as cognitive behavioural therapy and antidepressants has meant that the lives of millions of people have been transformed. But there remains a small cohort of people for which standard treatment does not work, and it is in this group that electroconvulsive therapy (ECT) is sometimes used. In fact, empirical evidence has shown it is the most effective treatment for severe depression, meaning people can resume work and relationships. Around 80 per cent who fail to respond to standard treatments for depression respond to ECT.

It is particularly useful in older patients who present with severe forms of depression where they are so depressed they refuse food and drink, appear confused or paranoid, or experience nihilism.

For these people, ECT can mean the difference between returning home or ending their days in an institution. It was first used in the 1930s after it was noticed that patients who had both epilepsy and mental health problems often improved after going into a convulsion.

But this is not the reality. It's now given while the patient is under a general anaesthetic with nurses, anaesthetists and psychiatrists present. The electrodes are carefully placed on the temples and gel is applied to prevent any burns to the skin and to conduct the charge more easily.

There is categorically no thrashing about of the limbs, patients are not restrained in any way and the most you can hope to see is a twitch of the eye lid. It's actually rather boring to watch, and new observers frequently express their disappointment that there wasn't more to see.

The aim of ECT is to induce a seizure in the patient and the electrical current needed to achieve this varies from individual to individual, but is usually in the range of 100-500 millicoulombs. The electrical charge lasts for no more than a few seconds, patients have to give their consent before undergoing ECT treatment and can withdraw this consent at any time.

Very occasionally, someone is so ill it is felt they are not capable of consenting. In these circumstances, two doctors and a social worker must assess the patient to detain them in hospital under the Mental Health Act and then an independent psychiatrist, sent by the Mental Health Commission, must assess the patient and agree that the treatment is necessary.

There are side-effects, although ECT is among the safest medical treatments given under general anaesthetic. The most commonly reported ones are headache, dizziness and memory problems. The latter is the one that causes the most concern. Evidence shows that memories formed in the period directly before or after the treatment can be affected, but that this usually improves within a few hours to a few weeks, if it occurs at all.

Longer-standing memory problems - where patients complain of gaps in memory for past events or biographical information - are associated with very high voltages of electricity, which are no longer used. There is no evidence that ECT, as practised in Britain today, causes permanent, severe memory disturbance, although the myth persists.

There is also no evidence that ECT causes any structural damage to the brain and in many ways is safer and has fewer side-effects than the medications we readily prescribe for depression. While the exact mechanism by which ECT works is not fully understood, we know that the seizure produces changes in the brain, at a molecular as well as cellular level, which "resets" the neurochemical equilibrium by increasing serotonin levels and the sensitivity of brain cells to serotonin.

It's not a panacea. It should be used carefully and only when clinically indicated. But ECT is an invaluable weapon in the arsenal used to fight depression. Having depression is nothing to be ashamed of and neither is having ECT. Depression kills and, sometimes, ECT saves lives.

ECT case study: 'ECT was my magic wand'

ECT in action: 'It made my mania worse' Doctors don't know how it works, so why use it? Lucy Parma, 30, a PA, had her first episode of depression at the age of 20, in her second year at university When you're depressed, people often say they wish they had a magic wand to make you better. Well, ECT was my magic wand.   Lucy had tried a host of anti-depressants I had several bouts of depression in my twenties - or, to give mine its proper name, unipolar, rapid-cycling depression (I would have severe downs, but never manic ups, once a year). All metaphors to describe it sound so banal, but for me it was like wearing sunglasses and earmuffs that cut me off from the world while I suffered torment in my brain. It was actively horrific, all the time, every minute of every day. My depression always took the same form. It started with anxiety and morphed into black despair. I would wake up early and feel sick. Then I would feel a physical change coming over my body - my chest felt heavy and my limbs rinsed through with a mixture of worry and inertia. Within a couple of days, I stopped functioning properly. I couldn't wash my hair, prepare food, or think rationally. I couldn't even bear to listen to music because it seemed so flippant. Last year it was as bad as it's ever been. I became blackly depressed for months, convinced I would never get better. My psychiatrist changed my pills again. I've had around half a dozen types of antidepressants. I've never really believed they've worked.

I've also had all sorts of therapy - cognitive behavioural therapy, group therapy, counselling and all the stuff they make you do in hospital (I had one stay in 2000 after a major panic attack) when you're too ill to fight them - like art therapy and drama therapy.

Nobody had suggested ECT until this last bout of depression, but after five months it was clear I wasn't getting better. ECT was always referred to as a last resort by my doctor, and that's pretty much where I was. It was a major decision to make. My doctor told me there were side?effects - normally short-term memory loss, but I didn't really care. By that stage in the illness, I was too numb and pessimistic.

So one Tuesday morning my lovely mum got up early and drove me to a private hospital. I'd had nothing to eat or drink since midnight because of the anaesthetic. A nurse took my blood pressure. I didn't have to change into a gown, I just took my shoes off and my doctor led me into a small room with a bed.

There was a machine by it the size of a microwave. I lay down on the bed, then my doctor asked me if I'd had a pee - which I remember finding a weirdly personal question. He explained you had to empty your bladder before a treatment.

A brisk anaesthetist gave me an injection in the back of my hand. I was also given a muscle relaxant to prevent convulsions. Someone put a blanket over me. Then I had the general anaesthetic: a sudden metallic taste in the mouth, then a wonderful swimmy feeling for three seconds before drifting into unconsciousness.

Then I woke up. And I was better.

I felt a bit confused, and I had a terrible ache in my jaw, but from the second I opened my eyes I felt more present in the room than I had felt for months. My spirit and personality had returned. The sunglasses and earmuffs were off. I was taken to a side room, and told it was fine to sleep, but I sat bolt upright on the bed, drinking everything in.

I had a few more sessions after that, even though I felt 100 per cent better by the time I'd had just two. Even in the later sessions, when they were more casual and started sticking the electrodes to my forehead before putting me to sleep (the general anaesthetic only lasts a few minutes and the current only passes through you for a matter of seconds), I wasn't scared.

My doctor said that it often works for people like that, which further suggested my depression was chemical in origin. It was a physical cure for a physical illness in my brain, rather than a behavioural disorder or reaction to an event. Understanding this also helps me.

I did have side-effects, but they were worth it - and would have been even if they were ten times worse. For the first few weeks I would completely forget things - entire conversations sometimes. But this became less pronounced, and went away after about four months.

More annoying was that I felt less mentally agile. I couldn't connect things so well - for example, if I'd seen a certain actor in another film I couldn't place them. My doctor explained that if you do a brainscan on someone who's had ECT, you can actually see that their brainwaves become wonky for three months, in a similar way to someone who's had an epileptic fit.

As far as I know, nobody understands how it works. But inducing a seizure seemed to rewire my brain. And now I've found something that actually works, I shouldn't need to live in dread of the black dog. If I get ill again, I can have ECT again.

I'd urge anyone with serious depression to try it. If you truly are at absolute rock bottom, you shouldn't be put off by fear, because it isn't possible for you to feel any worse. They press a switch, and it makes you better.

Lucy Parma is a pseudonym

ECT case study: A trigger for suicide

ECT in action: 'ECT was my magic wand' Doctors don't know how it works, so why use it? Terri Cheney, who has lived with manic depression since she was 16, claims ECT triggered a manic episode I had one move left - the one I'd kept on hand in case of an emergency. One phone call. It was to Dr R, the psychiatrist who promised that he could ease my pain if I would submit to a few months of electroconvulsive therapy. The decision to allow electrodes to be placed on each side of my skull, which would then transmit enough electrical voltage to send my body flying two feet off the operating table, was calm.   Terri's severe manic episode included a 24-hours-a-day shopping spree for 18 days Dr R was considered one of the top diagnosticians in the United States. When he spoke, I listened. All he said was: "ECT". The only possibility left was to try to shock the hell out of my depression. So I signed the 15-page consent form; three additional doctors confirmed the need. We all hoped that 12 ECT sessions, and many thousands of dollars later, I would be well again. Better than well - I would be cured. I remember almost nothing of the actual ECT, except the straps that bound me to the bed. They left bruises on my arms and ankles for weeks after each session. I'm not sure that I want to remember the experience. But whether I want to remember it or not is beside the point. The main side effect of ECT is that it wipes out your short-term memory. Some of it returns, but for me there are vast grey gaps in 1994. I forgot simple things. The meaning of certain words, the associations assigned to different colours. There seemed no functional distinction to me between red and green. (Fortunately, I was forbidden to drive while undergoing treatment.) I even forgot certain smells - smells that had once been as familiar to me as my father's face. Which I also briefly forgot. But I do remember the psychotic break that took place after my eighth ECT session, triggering the most severe manic episode of my life. Previous episodes had lasted several days. This one lasted weeks.

I may never be able to pin down the events of the non-stop, 24-hours-a-day, 18-day odyssey I embarked upon. What little I know of it, I pieced together through sales receipts.

I bought anything that struck my fancy, including a dozen assorted garden gnomes, even though I have no garden. By the time I got back home, I had not only gone through my entire savings account, I had seduced the husband of one friend and made plans to seduce another.

And then, after the ninth treatment, my world convulsed. I remember only two things about the next couple of months: first, Dr R was indicted for sexually molesting one of his patients, and his licence was suspended; second, I tried to commit suicide.

It's rather strange that I hadn't tried earlier, given the depth of my distress. But suicide requires movement, and depression weighs a thousand tons. I needed a spark of mania to fire up my resolve. Mania doesn't just give you the desire for extremes, it gives you the energy to pursue them.

I woke up in hospital three days after my attempt, in a private padded room on the locked ward. Who knows what went wrong during that last ECT session? I think it was some strange kind of gift from the gods. I emerged from that chaos a different person, with a different identity. No longer depressed, but [diagnosed as being] bipolar.

The label mattered. It made sense of my erratic life. I had never before understood how, for several weeks or months at a time, I could function at such a high level of competence, only to be followed by equally long periods of hiding under my desk, under the covers, in the dark.

I'm still ashamed of having a mental illness. But now it's mostly of the consequences, not the condition itself. I believe in this diagnosis. Despite the constant shifting of the earth beneath my feet, I feel grounded at last.

SHOCK THERAPY

A History of Electroconvulsive Treatment in Mental Illness

By Edward Shorter and David Healy

Electroconvulsive treatment - known as ECT - is a procedure that induces an epileptic seizure in the brain. Since it was introduced, in the 1930s, then refined and improved over the decades, it has provided relief for such torments as psychosis, suicidality, mania or depression of bipolar swings, symptoms of schizophrenia and the severe forms of depression.

Shock Therapy: A History of Electroconvulsive Treatment in Mental Illness, by Edward Shorter and David Healy, tracks the rise, fall and current return to grace of ECT. Though the authors claim it is a "careful ... fair and comprehensive investigation of ECT," it is hardly evenhanded. Rather, it is a polemic reproaching forces that the authors claim stood in the path of ECT during its dark days of reduced use, and a vindication of its stalwart supporters.

Little else could be expected from these co-authors. Shorter, Jason A. Hannah Professor of the History of Medicine of the University of Toronto, has made a minor specialty out of maligning psychoanalysis while recounting psychiatric history. David Healy, professor of psychiatry at Cardiff University, achieved notoriety several years ago when an offer of employment from University of Toronto was rescinded after he gave a lecture that raised questions about the role of Big Pharma in academic psychiatry.

As ECT was often rejected in favour of psychoanalytic approaches (or related psychotherapies), and psychopharmacology produced powerful drugs that seriously displaced ECT, this subject gives Shorter and Healy a chance to expound their shortcomings. It is hard to say whether they delight more in vindicating a valuable treatment or vilifying their favourite bêtes noirs.

But they deserve credit for trying to get a fair hearing for ECT, a much-misunderstood, sensationalized treatment. Their title, Shock Therapy, expresses the degree to which ECT evokes images of sizzling brains sending off sparks, a legacy of exaggeration in film and literature that is still distorted today by the likes of Naomi Klein, who features grisly, out-of-date clips of obsolete ECT techniques on her website.

Early witnesses to ECT were amazed by what appeared to be miracles: Patients who once lingered for years in unreachable states of agony and delusion returning to sanity after a few treatments. In 1938, the drama and excitement were so high at a pioneering ECT clinic in Rome that physicians were summoned to watch it by two blasts of a trumpet. The authors' account of the rivalries, personalities, schemes and plots of the early innovators in the field is highly engaging. Surely, psychiatrist Henri Bersot deserves a place in posterity for being the only physician known to experimentally administer ECT to himself.

That medical procedures and their progress cannot be separated from the march of social, cultural and political history is even truer in the case of a treatment for mental illness, for the traumas and dislocations that create suffering change the conditions in which the mentally ill are treated as well as the nature and definition of mental illness itself. The authors provide an illuminating account of the titanic waves of change that washed over ECT , including the arrival of randomized controlled studies, the emergence and development of informed consent, the shift in meaning of what constitutes the patient's risk, and society's ever-changing definition of mental illness.

As psychopharmacology alleviated such severe conditions as schizophrenia enough to allow previously institutionalized persons tolive in the community, such deviance became more normalized. But by creating and marketing drugs for more commonplace mental maladies such as chronic mild depression or anxiety, psychopharmacology also made normal mental anguish seem more pathological.

Shorter and Healy grapple with these social complexities with mixed success. In particular, their discussion of the influence of culture and the academy on ECT seems overly compressed. Statements such as "a transmission line runs from the senior common rooms through the newsrooms of the quality press directly into the nation's most literate and influential living rooms" do not apply equally to the entire period of ECT's existence, and require finer specificity.

While One Flew Over the Cuckoo's Nest and the suicide of Ernest Hemingway following ECT definitely an exaggerated negative impression, the authors do not pause to consider that most other mental- health treatments were not portrayed any more accurately. ECT had Jack Nicholson; psychoanalysis had Woody Allen. Granted, the maladies of the analysand are usually nowhere near as dire as the schizophrenic or suicidally depressed, but whether amusing or terrifying, neither film character served the public's understanding.

In their zeal to vindicate ECT, Shorter and Healy undermine their own credibility. For example, though psychoanalysts opposed ECT, their resistance was not monolithic, and the authors cannot really prove its impact. Quotes taken from their own interviews, such as, "The analysts pooh-poohed it but when their patients were suicidal they sent them for ECT. ... That's bullshit," only seem petty. The shrill mischaracterizations of psychoanalysis, anti-psychopharmacology rants and the inflammatory style - ECT and psychoanalysis are "gladiators ... vying for the prize"; evidence is "brandished" rather than presented - coat the entire text with a snide veneer.

This is unfortunate, because the basic contention that ECT is an effective treatment that was displaced to the detriment of many is true, and this chapter of medical history is genuinely fascinating.

Robin Roger is an editor of Ars Medica: A Journal of Medicine, the Arts and Humanities, as well as a psychotherapist.

He was bad, so they put an ice pick in his brain...

At the age of 12, Howard Dully was given a lobotomy, one of thousands performed by the notorious Dr Walter Freeman in the 1940s and 1950s. Now Dully has written a forceful account of his survival and sheds light on the man who subjected him to one of the most brutal surgical procedures in medical history

Elizabeth Day
Sunday January 13, 2008
The Observer

Dully was a withdrawn boy who liked riding his bicycle and playing chess. He occasionally fought with his brother, disobeyed his parents and stole sweets from the kitchen cupboards. He had a weekly paper round and was saving up to buy a record player. According to Dr Freeman's meticulous records, Dully was 62 inches tall and weighed 6½ stone. He was an average child, perhaps a little unruly but nothing that would strike one as exceptional for a boy of his age.

But Howard Dully would soon become exceptional for all the wrong reasons. Barely two months after this first meeting, his father and stepmother had him admitted to a private hospital in his home town of San Jose, California. At 1.30pm on 16 December 1960, he was wheeled into an operating theatre and given a series of electric shocks to sedate him. That much he remembers. The rest is murky.

When Dully woke the next day, his eyes were swollen and bruised and he was running a high fever. He recalls a severe pain in his head and the discomfort of his hospital gown, which gaped open at the back. He had no idea what had happened. 'I was in a mental fog,' Dully says. 'I was like a zombie; I had no awareness of what Freeman had done.'

What he didn't know was that he had been subjected to one of the most brutal surgical procedures in medical history. He had undergone a lobotomy and no one, not his parents, not the medical community or the state authorities, had intervened to stop it. More disturbingly, there seemed to have been no obvious necessity for the operation.

If Dully appeared superficially vacant or mildly aggressive, there were some obvious explanations. His mother died of cancer when he was five and his father, Rodney, later remarried to a 'cold and demanding' woman called Lou, who found her new stepson's natural ebullience and physical strength almost impossible to control. Relations between the two deteriorated so that Dully grew up in an atmosphere of emotional abuse and casual neglect. He was given regular beatings and forced to eat meals on his own. Increasingly convinced that there was something emotionally wrong with her stepson, Lou started consulting psychiatrists and mental health experts before eventually being referred to Dr Freeman, a renegade physician disowned by the mainstream establishment, who ran a private practice in Los Altos, just outside San Francisco. Freeman diagnosed Dully as a schizophrenic.

'He is clever at stealing, but always leaves something behind to show what he's done,' Freeman recorded in his notes from October 1960. 'If it's a banana, he throws the peel at the window; if it's a candy bar, he leaves the wrapper around some place... he does a good deal of daydreaming and when asked about it he says, "I don't know." He is defiant at times - "You tell me to do this and I'll do that." He has a vicious expression on his face some of the time.'

Discarded sweet wrappers, daydreaming spells and the odd glimpse of youthful defiance - it would appear to be a relatively innocuous list, but it was enough for Freeman. Eight weeks after the doctor first saw him, Dully came round from his operation in a state of numbed confusion. The hospital report stated that he had been given a 'transorbital lobotomy. A sharp instrument was thrust through the orbital roof on both sides and moved so as to sever the brain pathways in the frontal lobes'. Dr Freeman's bill came to $200. Dully was his youngest-ever patient; extraordinarily, he survived.

'People freak out when they realise the person they are talking to had a lobotomy,' he says now, 47 years later, sitting under the corrugated iron awning outside his trailer home on the outskirts of San Jose. 'They expect me to be drooling.'

Over the years, the lobotomy has become almost a caricature of itself, a cultural shorthand that immediately conjures up images of zombies or dribbling madmen. Even the word itself sounds freakish and unwieldy, like an ill-judged verbal joke. For most people, it remains indelibly associated with dramatic invention: with the dazed, incoherent character of Catherine in Tennessee Williams's Suddenly Last Summer or with Jack Nicholson's Oscar-winning performance as a deranged asylum inmate in One Flew Over the Cuckoo's Nest

But for a time in the 1930s and Forties, the procedure was at the forefront of neurosurgery, viewed by the medical establishment as a cutting-edge treatment for mental illness. Before the introduction of antipsychotic drugs or the popularisation of psychotherapy, the lobotomy was touted as a miracle cure for anything from schizophrenia to postnatal depression - and not just in the United States. Neurologists in the UK are estimated to have carried out 50,000 variants of the operation, until the late 1970s.

Derek Hutchinson, a 62-year-old grandfather, underwent a lobotomy in 1974 - without his consent, he says - at the hands of surgeon Arthur E Wall while a patient at the High Royds Asylum near Leeds. Unlike Dully, Hutchinson was awake throughout his operation, which a psychiatrist had insisted would curb his aggressive tendencies.

'What did it feel like?' he says from his home in Leeds. There is a long exhalation of breath on the end of the phone, halfway between a gasp and a sigh. 'It's a situation you should only go through once in your life and that's when you're dying. It felt like a broom handle was being pushed in my brain and my head was splitting apart.'

Originally developed by Portuguese physician Antonio Egas Moniz in 1936, the lobotomy involved drilling two small holes in either side of the forehead and severing the connecting tissue around the frontal lobes. The hope was to dull the symptoms of psychiatric illness by reducing the strength of emotional signals produced by the brain. Although Moniz won the Nobel Prize for his pioneering work in 1949, he insisted that it should only be used as a last resort, in cases where every other form of treatment had been unsuccessfully tried.

Dr Walter Freeman, a neurologist and Yale graduate, brought the procedure to America in the late 1930s. Freeman's first job after medical school was as head of laboratories at St Elizabeth's Hospital in Washington DC, a sprawling mental institution that housed 5,000 inmates in near-Victorian conditions. At the time, the state legislature paid a pitiful $2 a day per patient to cover their upkeep, a sum that included staff salaries, catering, accommodation and treatment.

Spurred on by his first-hand experience of the horrors of state-run mental institutions and determined to make his name as a medical pioneer, Freeman developed a version of Moniz's procedure that reached the frontal lobe tissue through the tear ducts. His transorbital lobotomy involved taking a kitchen ice pick, later refined into a more proficient instrument called a leucotome, and hammering it through the thin layer of skull in the corner of each eye socket. The pick would then be scrambled from side to side in order to damage the frontal lobe. The process took about 10 minutes and could be performed anywhere, without the assistance of a surgeon.

Over the years, Freeman developed a reckless enthusiasm for the operation, driving several thousand miles across the country to carry out demonstrations at asylums and hospitals. An instinctive showman, he sometimes ice-picked both eye sockets simultaneously, one with each hand. He had a buccaneering disregard for the usual medical formalities - he chewed gum while he operated and displayed impatience with what he called 'all that germ crap', routinely failing to sterilise his hands or wear rubber gloves. Despite a 14 per cent fatality rate, Freeman performed 3,439 lobotomies in his lifetime.

For the survivors, the outcomes varied wildly: some were crippled for life, others lived in a persistent vegetative state. Rose, John F Kennedy's sister, was operated on by Dr Freeman in 1941 at the request of her father. Born with mild learning difficulties, she was left incapacitated by the procedure and spent the rest of her life in various institutions, dying in 2005 at the age of 86. Yet occasionally, the operation appeared to have a calming, desensitising effect on the mentally ill. The lobotomy's mixed success rate was a symptom of its imprecision: it was a hit-and-miss procedure developed at a time when little was known about the very specific nature of the brain's structure.

Dully's almost total recovery is thus an anomaly. To look at him, you would never guess that he underwent such brutal surgery. There is no slowness of speech, no telltale squinting of the eyes, none of the lack of social inhibition that characterises most lobotomy survivors. Now 58, he has a full-time job training school bus drivers and has been married to Barbara for 12 years. He has a son, Rodney, 27, and a stepson, Justin, 30, and a tabby cat called Princess who prowls on a parched flowerbed while we talk. His autobiography, My Lobotomy, co-written with journalist Charles Fleming, was published in the US last autumn and will be published in the UK in March.

'I don't feel physically different from anyone else,' he says. 'I get eye infections because I think they destroyed my tear ducts. About the most unusual thing you would notice about me is my size.'

Dully is a broad, bulky man and 6ft 7in tall. When he turns on his laptop to show me photographs of his operation, his hand completely covers the computer mouse. The pictures are disturbing in their very matter-of-factness. Freeman was a fastidious archivist and insisted on recording each stage of the operation on camera. In one black-and-white image, Dully lies unconscious, his mouth lolling open. The tip of a 12cm long leucotome has been pushed deep into his eye socket. How does he feel when he sees these photographs?

'I would describe it as a feeling of loss, like you've lost a whole part of your life.' As he speaks, he gulps intermittently on a mug of milky instant coffee. 'I like hazelnut-flavoured cream in my coffee - it makes life worth living,' he says, grinning through an enormous walrus moustache. On the surface, at least, his life is settled, but it has taken Dully the best part of four decades to be able to speak with such ease about his past.

'It was something I didn't talk about for years. I felt that I was the secret, the skeleton in the closet, the dirty laundry.' That changed in 2003 when he was tracked down by an American radio production company and asked to make a documentary about his life. It was the first time he had seen his medical files and the first time he had found the courage to confront his past and speak to his father.

'Lou [his stepmother] had died in 2001, so a lot of what happened died with her. I asked my dad about it and I don't think he meant any harm. He said he got manipulated by Lou. She threatened him with divorce if he didn't go ahead with it. My dad said he only met Freeman once.'

Dully breaks off and leans back in his chair, arms folded across his black polo shirt. 'You meet a guy once and you're going to let him drive spikes in your son's head?' he asks, incredulously.

His father, now 83, has never apologised, but Dully remains astonishingly sanguine about the operation and the chequered legacy it left him. For years after the lobotomy, he was in and out of mental institutions, jails and halfway houses. He was homeless, drug-addicted and alcoholic, a petty criminal with little concept of how to live a normal life.

'I think I was angry at society for a long time, but I went through that and now I don't think there's any point in dwelling on it. I blame everyone for what happened including myself. I was a mean little ruffian. Lou was looking for a way to get me out of the house, for a solution to the problem, and Freeman was looking for a subject. Both of them came together... and whoopa-dee-doo.

'I don't think Freeman was evil. I think he was misguided. He tried to do what he thought was right, then he just couldn't give it up. That was the problem.'

In many ways, Walter Freeman was shaped as much by human frailty as his patients. Born in Philadelphia in 1895, he was driven from a young age to be exemplary, growing up in the long shadow cast by his grandfather, William Keen, an exceptional surgeon who was the first American successfully to remove a brain tumour. 'He was motivated partly by interest in the well-being of his patients and then also by this very urgent need to feel like he was someone who was accomplishing great things,' explains Jack El-Hai, author of The Lobotomist, a biography of Freeman. 'As he grew more personally attached to the lobotomy, he became more irrational.'

The more the mainstream medical establishment derided Freeman's methods - with the advent of Freudian psychoanalysis and antipsychotic drugs such as Thorazine in the mid-1950s the lobotomy fell out of favour - the more defensive Freeman became. He took pride in what he called 'shrink-baiting' and wrote disobliging limericks about his professional enemies, once saying he would 'rather be wrong than be boring'. By the time Freeman operated on Dully in 1960, he was working exclusively from a private practice - no state hospital would touch him.

Freeman's home life unravelled alongside his professional reputation. His wife, Marjorie, was an alcoholic and Freeman had numerous affairs. In 1946, Freeman had witnessed the horrific death of his 11-year-old son Keen on a camping holiday in Yosemite national park. Keen was bending down at the top of waterfall to fill up his flask when he lost his footing and was swept over the brink. It was an experience that must have affected Freeman greatly, although he made sparse mention of it in later life. But perhaps it was telling that, 14 years after the event, when he first met 11-year-old Howard Dully, Freeman suggested that the two of them should go hiking.

'My sense with Howard is that Freeman thought he was treating a family problem rather than just a boy's psychiatric problems,' says El-Hai. 'But by the standards he used in earlier years, what he did was completely unjustifiable.'

Although Freeman ended up causing unforgivable harm, he was not, essentially, a bad man. After he died of complications arising from an operation for cancer in 1972, his four surviving children - Walter, Frank, Paul and Lorne - became staunch defenders of their father's legacy. Two of them have carried on the familial medical heritage: Paul is a psychiatrist in San Francisco and the eldest, Walter Jnr, is now professor emeritus of neurobiology at the University of California.

Walter Jnr's twin, Frank, 80, is a retired security guard, living in a modest, second-floor apartment in San Carlos, just half an hour's drive from Howard Dully's home. He is a friendly giant of a man, dressed smartly in a double-breasted, dark blue suit and burgundy tie, kept in place by a thin gold clip. 'He was a marvellous father,' Frank says, sitting in a room filled with crossword dictionaries and Dick Francis novels. 'He loved his children and always made time for us out of his busy schedule, taking us camping every summer all across the country.'

Frank recalls being invited to observe a lobotomy when he was 21 and vividly remembers hearing 'a little crack as the orbital plate fractured. It only took about six or seven minutes and Dad kept up a running commentary.' Indeed, the original ice pick used for the first transorbital lobotomy came from the Freeman family kitchen drawer. 'We had several of them,' says Frank, cheerfully. 'We used to use them to punch holes in our belts when we got bigger. I'm enormously proud of my father. I do think he's been unfairly treated. He was an interventionist surgeon, a pioneer and that took guts.'

But however well-intentioned his interventions, Freeman's life-long quest for self-glorification meant that he failed to acknowledge when his methods were doing more harm than good. I ask Frank whether he thinks Freeman was justified in operating on the young Howard Dully, a boy on the brink of adolescence, whose brain had barely begun its transformation to maturity?

'Well...' he pauses, the palms of his hands resting on his knees. 'I've had a couple of chats with Howard [when Dully interviewed him for the 2003 radio broadcast] and he said that growing up, he hated his stepmother and she was afraid of him. He was belligerent and unco-operative, frightening if you like, and I'm convinced that if he'd gone on like that he would have ended up in jail or a mental institution. Frequently, people like Howard have a lobotomy and sooner or later they straighten out. Howard's been self-supporting for a number of years and he's married, in a very pleasant relationship.'

It is impossible to say how Dully's life would have panned out if he had not walked into Walter Freeman's office one long-ago autumn day. Perhaps it would, like Frank says, have been incalculably worse or perhaps it would have carried on much the same. But it could have been better, too, and the true sadness is that Howard Dully will never be able to find out one way or the other.

Mind-boggling: a history of lobotomy

1890: German scientist Friederich Golz experiments with removing the temporal lobe from dogs and reports a calming effect.

1892: Gottlieb Burkhardt, a Swiss physician, performs a similar operation on six schizophrenic patients. Four exhibited altered behaviour. Two died.

1936: Portuguese neuropsychiatrist Antonio Egas Moniz develops the leukotomy, but advises using the operation only as a last resort.

1945: American surgeon Walter Freeman develops the 'ice pick' lobotomy. Performed under local anaesthetic, it takes only a few minutes and involves driving the pick through the thin bone of the eye socket, then manipulating it to damage the prefrontal lobes.

1946: First lobotomy performed in Britain at Maryfield Hospital, Dundee. The procedure is used for 30 years.

1954: Antipsychotic drug Thorazine licensed for the treatment of schizophrenia, causing the lobotomy gradually to fall out of favour.

1960-70: Lobotomies come under scrutiny by sociologists who consider it a tool for 'psycho-civilising' society. They were banned in Germany, Japan and the Soviet Union. Limited psychosurgery for extreme medical cases is still practised in the UK, Finland, India, Sweden, Belgium and Spain.

psychosurgery review board

a feminist imperative  

by bonnie burstow

brain-disabling treatments in psychiatry

by peter breggin

electroshock as a form of violence agianst women

by bonnie burstow

electroshock is not a healing option 

a report from canada

the electroshock quotationary

by leonard roy frank

School of Shock

News: Eight states are sending autistic, mentally retarded, and emotionally troubled kids to a facility that punishes them with painful electric shocks. How many times do you have to zap a child before it's torture?

By Jennifer Gonnerman

August 20, 2007

Every time he woke from this dream, it took him a few moments to remember that he was in his own bed, that there weren't electrodes locked to his skin, that he wasn't about to be shocked. It was no mystery where this recurring nightmare came from—not A Clockwork Orange or 1984, but the years he spent confined in America's most controversial "behavior modification" facility.

In 1999, when Rob was 13, his parents sent him to the Judge Rotenberg Educational Center, located in Canton, Massachusetts, 20 miles outside Boston. The facility, which calls itself a "special needs school," takes in all kinds of troubled kids—severely autistic, mentally retarded, schizophrenic, bipolar, emotionally disturbed—and attempts to change their behavior with a complex system of rewards and punishments, including painful electric shocks to the torso and limbs. Of the 234 current residents, about half are wired to receive shocks, including some as young as nine or ten. Nearly 60 percent come from New York, a quarter from Massachusetts, the rest from six other states and Washington, D.C. The Rotenberg Center, which has 900 employees and annual revenues exceeding $56 million, charges $220,000 a year for each student. States and school districts pick up the tab.

The Rotenberg Center is the only facility in the country that disciplines students by shocking them, a form of punishment not inflicted on serial killers or child molesters or any of the 2.2 million inmates now incarcerated in U.S. jails and prisons. Over its 36-year history, six children have died in its care, prompting numerous lawsuits and government investigations. Last year, New York state investigators filed a blistering report that made the place sound like a high school version of Abu Ghraib. Yet the program continues to thrive—in large part because no one except desperate parents, and a few state legislators, seems to care about what happens to the hundreds of kids who pass through its gates.

In Rob Santana's case, he freely admits he was an out-of-control kid with "serious behavioral problems." At birth he was abandoned at the hospital, traces of cocaine, heroin, and alcohol in his body. A middle-class couple adopted him out of foster care when he was 11 months old, but his troubles continued. He started fires; he got kicked out of preschool for opening the back door of a moving school bus; when he was six, he cut himself with a razor. His mother took him to specialists, who diagnosed him with a slew of psychiatric problems: attention-deficit/hyperactivity disorder, post-traumatic stress disorder, bipolar disorder, and obsessive-compulsive disorder.

Rob was at the Rotenberg Center for about three and a half years. From the start, he cursed, hollered, fought with employees. Eventually the staff obtained permission from his mother and a Massachusetts probate court to use electric shock. Rob was forced to wear a backpack containing five two-pound, battery-operated devices, each connected to an electrode attached to his skin. "I felt humiliated," he says. "You have a bunch of wires coming out of your shirt and pants." Rob remained hooked up to the apparatus 24 hours a day. He wore it while jogging on the treadmill and playing basketball, though it wasn't easy to sink a jump shot with a 10-pound backpack on. When he showered, a staff member would remove his electrodes, all except the one on his arm, which he had to hold outside the shower to keep it dry. At night, Rob slept with the backpack next to him, under the gaze of a surveillance camera.

Employees shocked him for aggressive behavior, he says, but also for minor misdeeds, like yelling or cursing. Each shock lasts two seconds. "It hurts like hell," Rob says. (The school's staff claim it is no more painful than a bee sting; when I tried the shock, it felt like a horde of wasps attacking me all at once. Two seconds never felt so long.) On several occasions, Rob was tied facedown to a four-point restraint board and shocked over and over again by a person he couldn't see. The constant threat of being zapped did persuade him to act less aggressively, but at a high cost. "I thought of killing myself a few times," he says.

Rob's mother Jo-Anne deLeon had sent him to the Rotenberg Center at the suggestion of the special-ed committee at his school district in upstate New York, which, she says, told her that the program had everything Rob needed. She believed he would receive regular psychiatric counseling—though the school does not provide this.

As the months passed, Rob's mother became increasingly unhappy. "My whole dispute with them was, 'When is he going to get psychiatric treatment?'" she says. "I think they had to get to the root of his problems—like why was he so angry? Why was he so destructive? I really think they needed to go in his head somehow and figure this out." She didn't think the shocks were helping, and in 2002 she sent a furious fax demanding that Rob's electrodes be removed before she came up for Parents' Day. She says she got a call the next day from the executive director, Matthew Israel, who told her, "You don't want to stick with our treatment plan? Pick him up." (Israel says he doesn't remember this conversation, but adds, "If a parent doesn't want the use of the skin shock and wants psychiatric treatment, this isn't the right program for them.")

Rob's mother is not the only parent angry at the Rotenberg Center. Last year, Evelyn Nicholson sued the facility after her 17-year-old son Antwone was shocked 79 times in 18 months. Nicholson says she decided to take action after Antwone called home and told her, "Mommy, you don't love me anymore because you let them hurt me so bad." Rob and Antwone don't know each other (Rob left the facility before Antwone arrived), but in some ways their stories are similar. Antwone's birth mother was a drug addict; he was burned on an electric hot plate as an infant. Evelyn took him in as a foster child and later adopted him. The lawsuit she filed against the Rotenberg Center set off a chain of events: investigations by multiple government agencies, emotional public hearings, scrutiny by the media. Legislation to restrict or ban the use of electric shocks in such facilities has been introduced in two state legislatures. Yet not much has changed.

Rob has paid little attention to the public debate over his alma mater, though he visits its website occasionally to see which of the kids he knew are still there. After he left the center he moved back in with his parents. At first glance, he seems like any other 21-year-old: baggy Rocawear jeans, black T-shirt, powder-blue Nikes. But when asked to recount his years at the Rotenberg Center, he speaks for nearly two hours in astonishing detail, recalling names and specific events from seven or eight years earlier. When he describes his recurring nightmares, he raises both arms and rubs his forehead with his palms.

Despite spending more than three years at this behavior-modification facility, Rob still has problems controlling his behavior. In 2005, he was arrested for attempted assault and sent to jail. (This year he was arrested again, for drugs and assault.) Being locked up has given him plenty of time to reflect on his childhood, and he has gained a new perspective on the Rotenberg Center. "It's worse than jail," he told me. "That place is the worst place on earth."

04.01.2007

Disturbing News for Patients and Shock Doctors Alike

Something most remarkable and unexpected has occurred in the field of psychiatry. Lead by a lifelong defender and promoter of shock treatment, Harold Sackeim, a team of investigators has recently published a follow up study of 347 patients given the currently available methods of electroshock, including the supposedly most benign forms--and confirmed that electroshock causes permanent brain damage and dysfunction.

Based on numerous standardized psychological tests, six months after the last ECT every form of the treatment was found to cause lasting memory and mental dysfunction. In the summary words of the investigators, "Thus, adverse cognitive effects were detected six months following the acute treatment course." They concluded, "this study provides the first evidence in a large, prospective sample that adverse cognitive effects can persist for an extended period, and that they characterize routine treatment with ECT in community settings."

After traumatic brain damage has persisted for six months, it is likely to remain stable or even to grow worse. Therefore, the study confirms that routine clinical use of ECT causes permanent damage to the brain and its mental faculties.

The term cognitive dysfunction covers the entire range of mental faculties from memory to abstract thinking and judgment. The ECT-induced persistent brain dysfunction was global. In addition to the loss of autobiographical memories, the most marked cognitive injury occurred in "retention of newly learned information," "simple reaction time," and most tragically "global cognitive status" or overall mental function. In other words, the patients continued to have trouble learning and remembering new things, they were slower in their mental reaction times, and they were mentally impaired across a broad range of faculties.

Probably to disguise the wide swath of devastation, the Sackeim study did not provide the percentages of patients afflicted with persistent cognitive deficits; but all of the multiple tests were highly significant (p<0.0001 on 10 of 11 tests and p<0.003 on the 11th). Also, the individual measures correlated with each other. This statistical data indicates that a large percentage of patients were significantly impaired.

Many patients also had persistent abnormalities on the EEGs (brain wave studies) six months after treatment, indicating even more gross underlying brain damage and dysfunction. The results confirm that the post-ECT patients, as I have described in numerous publications, were grossly brain-injured with a generalized loss of mental functions.

Some of the older forms of shock--and still the most commonly used--produced the most severe damage; but all of the treatment types caused persistent brain dysfunction. The greater the number of treatments given to patients, the greater was the loss of biographical memories. Elderly women are particularly likely to get shocked--probably because there is no one to defend them--and the study found that the elderly and females were the most susceptible to severe memory loss.

Destroying Lives
The study does not address the actual impact of these losses on the lives of individual patients. Like most such reports, it's all a matter of statistics. In human reality the loss of autobiographical memories indicates that patients could no longer recall important life experiences, such as their wedding, family celebrations, graduations, vacation trips, and births and deaths. In my experience, it also includes the wiping out of significant professional experiences. I have evaluated dozens of patients whose professional and family lives have been wrecked, including a nurse who lost her career but who recently won malpractice suit against the doctor who referred her for shock. Her story is told on my website, www.breggin.com.

Even when these injured people can continue to function on a superficial social basis, they nonetheless suffer devastation of their identities due to the obliteration of key aspects of their personal lives. The loss of the ability to retain and learn new material is not only humiliating and depressing but also disabling. The slowing of mental reaction time is frustrating and disabling. Even when relatively subtle, these disabilities can disrupt routine activities of living. Individuals can no longer safely drive a car for fear of losing their concentration or becoming hopelessly lost. Others can no longer find their way around their own kitchen or remember to turn off the burner on the stove. Still others cannot retain what they have just read in a newspaper or seen on television. They commonly meet old friends and new acquaintances without having any idea who they are. Ultimately, the experience of "global" cognitive dysfunction impairs the victim's identify and sense of self, as well as ruining the overall quality of life.

Although unmentioned in the Sackeim article, in addition to cognitive dysfunction, shock treatment causes severe affective or emotional disorders. Much like other victims of severe head injury, many post-shock patients become emotionally shallow and unable to relate on an intimate or spiritual level. They often become impulsive and irritable. Commonly they become chronically depressed. Having been injured by previously trusted doctors, they almost always become distrustful of all doctors and avoid even necessary medical care.

Decades of Opposition to Shock Treatment
This breaking scientific research has confirmed what I've been saying about shock treatment for thirty years. In 1979 I published Electroshock: Its Brain-Disabling Effects, the first medical book to evaluate the brain damaging and memory wrecking effects of this "treatment" for depression that requires inflicting a series of massive convulsions on the brain by means of passing a traumatic electric current through it. After many rejections, the courageous president of Springer Publishing Company, Ursula Springer, decided to publish this then controversial book. Dr. Springer told me about venomous attacks aimed at her at medical meetings as a result of her brave act in publishing my work. She never regretted it.

Over the years, I have continued to write, lecture, testify in court and speak to the media about brain damage and memory loss caused by electroshock (e.g., Breggin 1991, 1992, 1997, and 1998). At times my persistence has resulted in condemnation from shock advocates such as Harold Sackeim and Max Fink whom I have criticized for systematically covering up damage done to millions of patients throughout the world. It would require too much autobiographical detail to communicate the severity of the attacks on me surrounding my criticism of ECT. It was second only to the attack on me from the drug companies for claiming that antidepressants cause violence and suicide.

Given the vigor with which shock doctors have suppressed or denigrated my work, the study further surprised me by citing my 1986 scientific paper "Neuropathology and cognitive dysfunction from ECT" published in the Psychopharmacology Bulletin, noting that "critics contend that ECT invariably results in substantial and permanent memory loss." They contrast this critical view with "some authorities," specifically citing Max Fink and Robert Abrams, who have argued against the existence of any persistent shock effects on memory. The implication was clear that the critics were right and the so-called authorities were wrong. Sackeim was among those authorities.
Fink's "authoritative" testimony at a number of malpractice trials has enabled shock doctors to get off Scott free after damaging the brains of their patients. Abrams used to testify successfully on behalf of shock doctors until I disclosed his ownership of a shock machine manufacturing company.

Unfortunately, the Sackeim group did not cite the work of neurologist John Friedberg who risked his career to criticize electroshock treatment. Nor did their article give credit to the published work of psychiatric survivor Leonard Frank or the anti-shock reform activities of the survivor moment lead by David Oaks of MindFreedom. They also didn't cite Colin Ross's 2006 review and analysis showing that ECT is no more effective than sham ECT or simply sedating patients without shocking them.

Will the latest confirmation of ECT-induced brain damage cause shock doctors to cut back on their use of the treatment? Not likely. Psychiatrist and their affiliated neurosurgeons always knew that lobotomy was destroying the brains and mental life of their patients and that knowledge did not daunt them one bit. It required an organized international campaign to discredit, to slow down and to almost eliminate the surgical practice of psychiatric brain mutilation in the early 1970s (Breggin and Breggin 1994). The ECT lobby is much larger and stronger than the lobotomy lobby, and much better organized, with its own journal and shock advocates positioned in high places in medicine and psychiatry. Stopping shock treatment will require public outrage, organized resistance from survivor groups and psychiatric reformers, lawsuits, and state legislation.

This essay will appear in Dr. Breggin's column, "Politics, Practice and Breaking News," in a forthcoming issue of the journal Ethical Human Psychology and Psychiatry, sponsored by the International Center for the Study of Psychiatry and Psychology (www.ICSPP.org).

References
Breggin, P. (1979). Electroshock: Its brain-disabling effects. New York: Springer Publishing Company.
Breggin, P. (1991). Toxic psychiatry. New York: St Martin's Press.
Breggin, P. (1992). The return of ECT. Readings: A Journal of Reviews and Commentary in Mental Health, 3 (March, No. 1), 12-17
Breggin, P. (1997). Brain-Disabling treatments in psychiatry. New York: Springer Publishing Company.
Breggin, P. (1998). Electroshock: Scientific, ethical, and political issues." International Journal of Risk & Safety in Medicine 11, 5-40.
Breggin, P. and Breggin, G. (1998). The war against children of color. Monroe, Maine: Common Courage Press.
Frank, L. (1978). (Ed.). The history of electroshock. Available from L. Frank, 2300 Webster Street, San Francisco, CA 94115. Also available on www.Amazon.com.
Frank, L. (1990). Electroshock: death, brain damage, memory loss, and brain washing. Journal of Mind and Behavior, 11, 489-512.
Frank, L. (2006). The electroshock quotationery. Ethical Human Psychology and Psychiatry, 8, 157-177.
Friedberg, J. (1976). Electroshock is not good for your brain. San Francisco: Glide Publications.
Friedberg, J. (1977). Shock treatment, brain damage, and memory loss: A neurological perspective. American Journal of Psychiatry, 134, 1010-1014.
Ross, Colin (2006). The sham ECT literature: Implications for consent to ECT. Ethical Human Psychology and Psychiatry, 8, 17-28.
Sackeim, H., Prudic, J., Fuller, R., Keilp, J., Lavori, P. and Olfson, M. (2007). The cognitive effects of electroconvulsive therapy in community settings. Neuropsychopharmacology, 32, 244-254.

ELECTROSHOCKING ELDERLY PEOPLE: ANOTHER PSYCHIATRIC ABUSE

by Don Weitz

“Electroshock is violence.”

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