The following is an excerpt from my memoir Seeking Happiness: A Bipolar Story:
My electroconvulsive therapy (ECT) required that I wake up at four o’clock in the morning. Practitioners of ECT are few and far between, so I had to travel two hours to see the one nearest me bright and early to make a seven a.m. appointment. I did not have to worry about breakfast since I couldn’t eat or drink anything for the eight hours preceding my procedure. One of the modern features of ECT is that it is performed under general anesthesia, hence the dietary restrictions. This modern feature prevents the injuries and discomfort that come from the convulsions caused by ECT.
A friend agreed to drive me to the facility since I couldn’t drive myself home afterwards. Once we got there, I had to change into the conventional hospital gown and socks. The gown was a hideous gray with a light pattern of rectangles across it to give it some life. Naturally, it was open in the back, exposing my posterior.
A nurse came in after I was dressed in my gown and socks, aiming to insert one of the longest needles I had ever seen into my hand. She prepped me with a local anesthetic to numb it in case she had to fish the needle around. Then she stuck me and, thankfully, got it right the first time. Another nurse reviewed with me what I was agreeing to and obtained my written consent for the procedure. ECT cannot be administered involuntarily without a court order.[i]
Then I got to meet Dr. Noah, my new psychiatrist, for the first time. He was a veteran clinician and had the white hair to prove it. He had almost thirty years of experience, and as a practitioner of ECT, he had extensive experience with the worst cases of mental illness.
He started off by immediately telling me he had reviewed my entire case, and he wanted to assure me that I had plenty of options: I could double my lithium dose and still be within acceptable levels. Furthermore, newer alternatives to lithium have been introduced with which I may have better results. My Latuda could be more than doubled – almost tripled in fact. My hydroxyzine works well for general anxiety, but if I wanted to stomp out anxiety and panic attacks, he was willing to prescribe benzodiazepines, an extremely effective but also addictive class of anti-anxiety medications. He also pointed out that my albuterol inhaler could cause panic attacks and prescribed a safer alternative in its place. He wasn’t trying to prevent me from undergoing ECT; rather, he was talking about the medication he wanted to use in conjunction with ECT.
Dr. Noah left and two nurses stepped in. They told me generally what to expect from the procedure and then wheeled me into the operating room. They put electrodes on my chest and side to monitor my vital signs. Dr. Noah wiped alcohol pads on my face to prep me before putting more electrodes on me. He placed four electrodes on my face to measure my brain activity, and because he was administering bilateral ECT, he placed two large black transmitters on my temples that would deliver the arc of electricity that initiated the seizure. My heart was pounding because the operating room was a genuinely scary place. After all the electrodes had been placed, the anesthesiologist injected sedatives into my intravenous line, which was by far the scariest part of the entire procedure. The last thing I felt was a painful stinging sensation as the sedative spread upward in my arm through my veins into the rest of my body. My heart raced as it spread, and I felt almost in a panic. Then I lost consciousness.
I woke up dazed. I struggled to open my eyes. I saw someone sitting beside me, but then my eyes forced themselves shut again. Eventually, I was able to keep them open, but I could not move. The man sitting beside me was my nurse, and he brought me a cup of water. I tried to raise my head to drink from it, but my neck refused to budge. He tried bringing the water to my mouth, but I found myself struggling to swallow it, and I choked on it. He left the cup of water in my hand and went to summon the doctor. With great effort, I raised my head just enough to drink. I found out later that the anesthesiologist had not given me enough sedative during the procedure, and therefore my muscles had convulsed excessively, resulting in the total body stiffness that I was experiencing.
Dr. Noah came in and talked with me about how he wanted to modify my medication. He wanted to switch me from lithium to the mood stabilizer oxcarbazepine (trade name Trileptal) and asked if I was okay with that. He had mentioned it in the pre-op visit, saying that it had replaced lithium as the drug of choice. I knew he was wrong from my research. Lithium was still considered a first-line treatment option, and oxcarbazepine, on the other hand, was only considered a supplementary mood stabilizer.[ii] I thought this change had something to do with my decision overdose on lithium. I had to admit, however, that I was still cycling between mania and depression while on lithium, and if this drug could stop the cycling, I was willing to go for it. So I acquiesced, deciding to trust my doctor’s expertise, and I stopped taking lithium and started taking oxcarbazepine in its place.
The second treatment went without incident. It was performed two days after the first on a Wednesday. The following treatment would be on Friday, the next on Monday, and so on. Dr. Noah prescribed a muscle relaxant to help with muscle stiffness following the procedure, and my anesthesiologist increased my sedative during the procedure to reduce postoperative stiffness. Starting with the third treatment, I had to come in an hour earlier to work with the hospital’s schedule, so our four a.m.’s became three a.m.’s.
My third treatment was different from my first two because the initial seizure that morning was not strong enough, so Dr. Noah told me he had to initiate a second. With each subsequent treatment, stronger and stronger electrical pulses were being used to create greater and greater seizures. The third treatment was delivering pulses halfway to the maximum strength established as the goal. The fourth and fifth treatments were administered without problems. Starting with the sixth treatment, maximum strength electrical pulses would be used.
Before my fifth treatment, Dr. Noah told me he wanted to start me on nortriptyline (trade name Pamelor), a tricyclic antidepressant (TCA). At first, I thought the doctor had lost his mind. TCAs are notorious for causing antidepressant-induced mania – in fact, they do so more often than any other medication.[iii] Furthermore, without mood stabilizers (I also presume that includes the use of ineffective ones like oxcarbazepine) it had been proven that some people with bipolar disorder experience cycle acceleration brought on by the use of a TCA.[iv] This acceleration could range from inducing rapid cycling to experiencing greater day-to-day mood instability.
In addition to the bad reputation TCAs have, I had a positive history of antidepressant-induced mania with SSRIs and SNRIs, two classes that induce mania at significantly lower rates than TCAs.
There is a place for using TCAs in bipolar depression, but that place is at the bottom of the list. Its risks are great: switches into mania/hypomania, cycle acceleration, prominent side effects, and the acute risk of lethality if overdosed upon, but its benefits may outweigh the risks because of how powerful TCAs are on depression. Any psychiatrist prescribing a TCA should in theory evaluate the risk vs. benefit of doing so.
Dr. Noah didn’t give me the impression he did that, however. He said unashamedly he chose a TCA because it would remain effective for fifteen years, compared to the burn-out rate of three years for modern antidepressants. The problem was the drawbacks seemed to substantially outweigh the convenience of an antidepressant lasting fifteen years.
I brought up my concern to Dr. Noah, but he dismissed them as unfounded. I didn’t want to give in, but I thought to myself, “I have been very actively involved in the medicine I have been prescribed, and it has not been effective for me at all. Maybe I should trust his judgement. He knows what he is doing.” With that, I acquiesced and started taking nortriptyline. I noticed that it immediately made it harder for me to sleep, which is counterintuitive because nortriptyline is known to cause sedation. It was the first sign that nortriptyline was activating the mania inside of me. Dr. Noah said it was nothing to worry about and simply to take it in the morning instead.
I told Gabriel about starting ECT, and naturally after my third or fourth treatment he asked me how my treatments were coming along. I looked at him confused, and said, “Gabriel, how did you know I was undergoing ECT?” Retrograde amnesia, or losing memories from before my treatment, was a common side effect of ECT, but these memories were typically fully recovered within six months of finishing treatment. A rare side effect was anterograde amnesia, or not forming new memories following an ECT treatment. Following my eighth treatment, I bought a new car the next day and was several hours late to work because of the paperwork involved. When the tardy popped up on my record, I was on the verge of debating it with my manager when Gabriel explained that it was not a mistake. I had forgotten I had bought a car – the very car I drove to work every day.
My sixth treatment went well, but upon returning home, my suicidal ideation started to pick back up again. I kept getting bogged down by this lack of purpose I felt. I was not motivated to do anything, and it left me with a sense of unease. These feelings were most intense on the same day as the treatment. With my seventh treatment, the same thing. When it faded, though, I perked up significantly. Although I still felt bad on the same day as the treatment, the following day the sky seemed bluer, the grass greener, and my room even brighter. I could feel the inside of my mind changing. I felt inexplicable happiness and had difficulty comprehending it. My body was starting to respond to ECT treatments on one side and my TCA on the other. After my eighth treatment, though, I felt horrible. I had lost the happiness that had followed my seventh treatment, and in its place I felt an intense jitteriness. I found that being in one spot was especially difficult. I felt off-kilter, and no position felt natural to me.
It was akathisia I was feeling – that intense restlessness that moving around can’t quite placate. The anesthesiologist added haloperidol (trade name Haldol) to the ketamine he used to sedate me, most likely as an antiemetic to prevent postoperative nausea or even vomiting that can follow general anesthesia. Haldol is an older drug that had at one time been prescribed off-label for bipolar disorder. It fell out of favor, however, because of its prominent side effects, including akathisia and its risk of triggering depression. But like any other drug, Haldol flushed out of my system and my akathisia and suicidal ideation went along with it.
By the second day after my eighth treatment, not only had I found peace from my jitteriness, but I was in nirvana. If I had not directly experienced it, I would not have believed it to be possible. But it was true. I felt so good; I was sure that my antidepressant had turned me manic just as I had feared it would. This was the only explanation that made sense to me, but then I started assessing myself for mania and found no symptoms. I was not extremely goal oriented. I was not distractible. I was sleeping well at night. I was neither talking fast nor was I experiencing ideas moving wildly and rapidly within my mind. I was not spending my money uncontrollably. I was not manic. The nirvana I felt was real!
After struggling with bipolar disorder for seven years, being in psychotherapy for years, taking over a dozen different drugs, being hospitalized once, attempting suicide, and constantly cycling between mania and depression, I never expected that I would be better. I thought I would always be trapped in my bipolar disorder. Then I opened my eyes one morning following a successful administration of electroconvulsive therapy, and I felt a deep happiness and tranquility that I had not known before. I had done it I thought: I had overcome bipolar disorder!
[Plot twist: I was manic as hell because my antidepressant had caused me to switch.]
 Doubling or tripling my Latuda dosage would not have helped. Doses above 60 mg (which I was taking) are not more effective for treating bipolar depression and are more appropriate for individuals with schizophrenia. (See Miklowitz and Gitlin, Clinician’s Guide to Bipolar Disorder, [New York: The Guilford Press, 2014], 91.)
[i]. Eugene Rubin and Charles Zorumski, “Can the Mentally Ill be Hospitalized Against Their Will?” Psychology Today, October 28, 2010., accessed February 5, 2019. https://www.psychologytoday.com/us/blog/demystifying-psychiatry/201010/can-the-mentally-ill-be-hospitalized-against-their-will.
[ii]. Stephen M. Stahl, The Prescriber’s Guide: Stahl’s Essential Psychopharmacology, 4th ed. (Cambridge: Cambridge University Press, 2017),439.
[iii]. Iwona Koszewska and Janusz K. Rybakowski, “Antidepressant-Induced Mood Conversions in Bipolar Disorder: A Retrospective Study of Tricyclic versus Non‑Tricyclic Antidepressant Drugs,” Neuropsychobiology 59, no. 1 (March 2009): 12–16. http://dx.doi.rgp/10.1159/000202824; Miklowitz and Gitlin, Clinician’s Guide to Bipolar Disorder, 98–99.
[iv]. Miklowitz and Gitlin, Clinician’s Guide to Bipolar Disorder, 99.