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A Shock to the System Long dismissed as more cruelty than cure, electrotherapy to 'fix' the charge in depressed people's brains is gaining new respect among psychiatrists.

THE BALTIMORE SUN

Until this year, Bob Cadmus was too afraid of people to speak to them.

He had it all worked out so he wouldn't have to. He sought solitary jobs -- house painter, bus driver, boardwalk funnel-cake cook. He had a room at home where he could hide at the first sign of conflict. He didn't have friends, other than a few guys he met in kindergarten who didn't mind that all he said was "yeah" and "yeah."

His face fixed in a smile, he appeared as a pleasant, jolly, working man; older than 46, perhaps, his skin toughened by ocean sun and salt, but contentedly in his prime. That's how he hoped people saw him, anyway, so they wouldn't pry.

Quiet and shy, some said. His wife thought so, too.

Nobody knew how depressed he was until 10 years ago, when the darkness took over his mind and he lost control. He swallowed too many pills and woke up in a psychiatric hospital.

It was a scene that was to repeat itself many times throughout the decade. His wife and daughter became accustomed to his on-again, off-again stays in psychiatric hospitals, his fear of strangers so intense he couldn't join them at church. Finally, they left him alone in his room.

Eventually, doctors agreed on a diagnosis: socio-phobia and post-traumatic stress syndrome. They gave him a nickname, too: the Smiling Depressant. But the drugs they paraded out one by one did nothing for him. Inside was a man who could think only bad things. Outside, a man so quiet that even his therapist fell asleep.

The dark place is gone now. Cadmus no longer hides in his room. He rejoices in simple things: the singing of birds he now hears each morning out on his porch in Berlin, where he takes his coffee and smokes a cigarette.

Why did he have to wait all these years for help? Surely his smile tripped him up, but so did social attitudes about what ultimately helped him: shock therapy.

Public fear and distrust of shock therapy was sealed when it was portrayed as a savage punishment in the 1975 movie "One Flew Over the Cuckoo's Nest." For years, the treatment receded into the remote corners of psychiatry.

Now, quietly, steadily, electroconvulsive therapy, ECT, is returning to mainstream therapy -- lifesaving news for people like Bob Cadmus.

Defining the problem

When Cadmus arrived at Baltimore's Sheppard and Enoch Pratt Hospital last March after a second suicide attempt, the doctor asked what he asks all patients: "What are you depressed about?"

Cadmus answered the way many patients do: describing a social problem. Often in depression cases, experts believe, a social problem eventually triggers a chemical problem, an imbalance in the brain. Many years ago, as Cadmus sought to make sense of alcoholic parents who kept him up all night with their fighting, his brain began to go awry.

His smile was his protection.

Underneath was a nervous, anxious child. Rarely did he speak and rarely did he remember what he read. His mind drifted. He was held back grade after grade. School didn't much matter to Cadmus in the '50s in Ocean Grove, N.J., because he knew what he was coming home to -- fighting parents or nobody. One year he went to school only 45 days. The rest of the time he hung out on the boardwalk in Asbury Park.

And smiled.

"That was just my way of hiding things from people," Cadmus says. "So I didn't have to deal with other people's questions."

When he finally dropped out at age 16, he hadn't passed seventh grade. In his 20s he began seeing a psychiatrist and taking anti-depressants. He worked odd jobs, but his self-image was so poor that when his childhood dream of driving a bus came within reach, he let it slip through his fingers.

In the early 1970s, pushed by his then-psychiatrist, Cadmus went so far as to borrow a bus from a school, learn to drive it, pass the test and get himself hired as a bus driver in New York City. But on the first day, even before he sat behind the wheel once, he quit. Driving wasn't the problem; it was the idea of doing anything.

He went back to the odd jobs. For a while he ran a backhoe and dug ditches for a shore town in New Jersey. Standing around made him anxious, though, so he quit to wash windows, a job he says was "made for me." Early every morning, before opening hours, he worked alone.

Along the way, he met a woman in a pool hall, Patti, and married her in 1976. In the mid-1980s, when their daughter was 5, Cadmus persuaded his wife to move to the Eastern Shore because crime was lower and living cheaper.

There, seven years ago, Cadmus finally succeeded in obtaining his dream job -- driving a bus. Few people understood how he could be so happy about carrying drunken, singing vacationers up and down the streets of Ocean City.

A few years later, Cadmus says, "things just started going downhill again. ... I kinda self-destructed."

By then, he had been through dozens of anti-depressants prescribed by his doctor; they now left him more anxious or worse. He started sleeping too much or not at all. He erupted in anger or stayed silently in his room, listening to music. He saw himself as an object, and then, in the logic of the profoundly depressed, as an object that shouldn't be there. Finally one morning in the early 1990s he awoke in the hospital after his first suicide attempt: an overdose.

It was then that doctors concluded Cadmus was a good candidate for shock therapy. He spent a few days at a Delaware hospital learning about it from training films and seminars.

The day he was to begin it, he was in the hospital kitchen making coffee when the doctor who was to treat him passed by.

"I smiled," Cadmus says.

That afternoon, the doctor came to see him. She handed him a prescription for a drug he'd already tried and told him she'd canceled the ECT. "She said she decided not to do it because she saw me smiling," Cadmus says.

He emerged from the hospital worse than before, he says. He tried cutting his wrists and he drank heavily. Drinking was the only way he could talk to someone and not be afraid, he says. Drunk one day, he intentionally drove into a telephone pole. He served eight days in jail, lost his driver's license and his dream bus driver's job. "I was desperate to die," Cadmus says. "Then my anger would build, and come out."

Last spring, taken to a hospital after another overdose, he escaped from the emergency room. What was the point in staying for more pills that didn't work? he asked his wife hours later when he finally called her to come get him.

The next day his doctor called Sheppard Pratt and said Cadmus was ready for the last resort, shock therapy.

No-pain therapy

The first treatment was on a Wednesday.

The psychiatrist, Jack Vaeth, met him in a small room. As he does with all patients, the doctor attached electrodes to Cadmus' head, then pushed a button that sent more than 100 volts to the patient's brain.

For Cadmus, this was painless: Before the shock, he had received a muscle relaxant and anesthesia. During the shock itself, a respirator took over his breathing for a minute.

The whole thing took 15 minutes. Cadmus got up right away, surprising the nurses. He wasn't groggy. He didn't have a headache. He walked away.

This time the smile on his face was real. For the first time, he says, he felt like a person.

"I just had a lot of hope, that was the main thing ... it was a chance for me I really never had, so I was kind of, I guess, joyous ..."

Three times a week for a month, Cadmus was treated with shock therapy, and after he left the hospital he got two more treatments as an outpatient. After each session, he felt better.

He slept though the nights. He exercised. He went to every group session his doctor suggested. He even agreed to accompany another patient to a session on alcoholism. "I could communicate a little bit with somebody and I felt happy about myself," he says.

'Rebalancing chemistry'

What happened inside his brain remains a mystery. Doctors believe that sending electricity to the brain ignites a seizure that shuffles up the brain's chemistry, cleaning it out for the free flow of seratonin, a kind of brain vitamin. "We are rebalancing chemistry," says Vaeth, the psychiatrist.

ECT was invented accidentally, in 1938, by an Italian doctor who noticed that mentally ill patients improved after having a seizure. In the 1940s and 1950s, it was given out indiscriminately, like breakfast on a rolling cart. It was gruesome in its primitive stage: Patients were held in restraints, their faces turned blue from a momentary lack of oxygen; sometimes their bones broke from the force of the convulsion. When anti-depressants came along in the mid-1950s, ECT quickly died out. Most medical schools had stopped teaching by the time of "Cuckoo's Nest."

By the mid-'80s, modified with muscle relaxants and anesthesia to eliminate its gruesome aspects, ECT began its quiet comeback. It works more quickly, more effectively and with fewer side effects than drugs on patients on the brink of suicide.

Doctors brought it back to Sheppard Pratt because anti-depressants failed with half their depressed patients and because many older people couldn't mix anti-depressants with other medicines. Something was needed because chronic depression is incurable, and drugs cannot help a third of depressed people, according to the American Psychiatric Association (APA).

As a treatment for depression, ECT is still a last resort. But it has become the treatment of choice for a small but growing number of chronically depressed people. Eighty percent of shock-therapy patients recover from an episode of profound depression, compared with 60 percent for those treated with antidepressants, says the APA. What's more, for some reason anti-depressants work better after shock therapy.

"For the right person it is still probably the best treatment we have," says Richard Wyatt, director of research at the National Institute of Mental Health.

Sheppard Pratt recorded 2,200 treatments last year, up from 1,900 the previous year. Some 60 percent were outpatient. Since patients are more likely to relapse without more ECT or drugs or both, ECT is becoming a way of life for some. In fact, the hospital says 10 percent of ECT treatments are "maintenance" or preventive therapy. Booster shocks, if you will.

One patient has received shock therapy every week for several years now. The majority return every three months to six months for up to five treatments each time. Many are able to work the next day after suffering only the equivalent of a 45-minute hangover.

One Baltimore patient -- 42, married and the father of three -- has received dozens of treatments since January and recovered enough this fall to fill in as a supervisor and to put his name in contention for the permanent job.

"... [T]hey put this band around your head and sometimes the adhesive they use to strap [it] on your head, the glue is still on the forehead and in my hair a little bit. It can be quite unsettling at times when I think about it. It's not [that] I go into a panic or anything, I have been doing it so long."

Underused

Still, shock therapy is underused in this country because people are so terrified of it, Wyatt and other experts say. Doctors have repeatedly fought legislative attempts to restrict its use in California and Texas.

Shock therapy's worst side effect is temporary memory loss, doctors say.

For many people, the memory loss is limited to the time around the treatment itself and may last days or weeks. The experience is unpredictable.

One Sheppard Pratt patient found himself unable to recall a post-ECT trip to Disney World without prompting from photos.

After her shock therapy, one Baltimore nurse endured two frightening months in which she couldn't recall how to get to her child's day-care center or how to complete paperwork for her job. Unable to work, she stayed home. She imagines she read, but she can't say what. She does remember that she constantly double-checked whether she changed a diaper or turned off the oven. From her husband, she knows friends came to visit, but she doesn't remember them.

The worst day came when she apologized to a friend for missing the annual church party and learned an upsetting truth: "But you were there," the friend told her. "You even signed the guest book!"

"People told me I was like a shell -- not there," the woman recalls. "It was like, 'Knock, knock, nobody's home.' "

The treatment snapped her out of her acute depression, but she was too frightened to consider it again.

Cadmus, too, was afraid, but a poor memory didn't scare him as much as depression. He wouldn't have tried to kill himself so many times if he'd had been treated sooner, he says.

When he returned home from Sheppard Pratt, at first he couldn't remember the name of the street he lived on. But for him, he says, that is not unusual -- he often forgets names. For him, the choice was clear.

"If someone had suggested cutting off my head and sewing it back on I would have done it, to get relief from my inner thoughts," Cadmus says.

Planning a future

As he tells his story, he sits at the dining-room table, his hands folded on the lace tablecloth. They shake interminably at each new question.

A few days after he arrived home from Sheppard Pratt, he went out drinking and landed back in the local psychiatric ward for a night. He's at a loss to explain why it happened since he was feeling so much better.

"Habit, I guess," he says.

At least now he imagines a future. It could include a full-time job again. Painting the house is on his agenda. On one recent day he raked 20 bags' worth of leaves. He still can't go to church -- people are too friendly -- but he did accompany his daughter on a camping trip with a Christian group last summer.

He has hope. Right now he's hoping for the holiday season to be over.

The hustle and bustle, the worry over finding the right presents and the family reunion make him nervous even with his anxiety medication.

In past years, he was afraid of Christmas shopping -- crowds made him sweat. This year he didn't think about it.

Talking to others will never be easy for Cadmus, but he says he's now willing to work on it with a therapist.

Each morning as he takes his coffee onto the porch, he looks forward to the day. "I never make things happen," he says, "so I look for something to happen."

His fishing buddies, the pals from kindergarten, aren't content anymore to just see a smile. He's confided in them about his illness. From time to time, they ask him how he's doing. "It makes me feel good," Cadmus says. "I never had that. Nobody ever thought to ask."

Pub Date: 12/28/98

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