"I just went to bed," Brooks says. "I didn't want to talk to anyone. I just wanted everybody to leave me alone."

As a married man with two kids who owns a turkey farm in Union County, Brooks, 68, didn't have time to be sick. He went back to his doctor who, like the last time, prescribed a series of anti-depressants. "I took every kind of pill imaginable, but it didn't do me any good," he says.

As his depression grew progressively worse, his doctor recommended he go see a practitioner in Charlotte who specialized in treating depression. When it was first suggested that he try electroconvulsive therapy (ECT), Brooks balked. "I just didn't like the idea," he says.

But as he continued to spiral downward, he finally agreed.

In 1938, at the Department of Mental and Neurological Disease at the University of Rome, Dr. Ugo Cerletti began experimenting with a new electroshock apparatus to provoke epileptic fits in dogs and other animals. Then, after watching pigs being anaesthetized with electroshock before being butchered, he was struck with an epiphany: Why not try it on humans? In collaboration with Dr. Lucio Bini, Cerletti administered a series of electrical currents into the brain of a 39-year-old mental patient who had been diagnosed with schizophrenia. The electrical currents triggered patient convulsions and seizures, just as they had previously in the animals. After 11 such treatments, Cerletti determined he had successfully reversed the patient's psychosis. This was the first time a doctor had administered what is now known as electroconvulsive therapy (ECT). Today, according to the American Hospital Association, as many as 100,000 people receive ECT annually in the US, including many here in Charlotte.

Although there have been many technological and medical advances over the years, ECT remains a controversial and stigmatized treatment. Proponents say that's largely because of media misinformation, and stress that not only is ECT safe, but it is one of the most effective ways to treat depression, bipolar disorders, schizophrenia and other mental disorders. Critics, however, say the procedure is not properly regulated, and can cause serious and damaging side effects. We talked to some Charlotte area doctors and ECT patients to find out why this controversial treatment once considered so violent and inhumane is now making a comeback.

On the morning of Sept. 8 last year, Brooks and his wife arrive at CMC for his first ECT session. They take the elevator up to the psychiatry department on the fifth floor, and are led to an operating room. Brooks strips down to his underwear, dons a hospital gown, and stretches out on the bed. Nurses cover him with a couple of blankets to keep him warm. An intravenous anesthetic is administered, as is oxygen and a powerful muscle relaxant. Monitoring sensors are placed on his head and body to record his heart rate and brainwaves; blood pressure cuffs are placed on his arm and leg. A bite block is inserted into his mouth to prevent him from biting his tongue during the convulsions. Finally, a nurse attaches electrodes to both his temples. Brooks takes a long, nervous breath.

During the 40s and 50s, the first generation of ECT devices, called sine wave machines, were often used not to heal but to control troublesome and unruly mental patients. These early machines sent out intense bursts of electricity that often produced memory loss, brain damage and a host of other harmful side effects. This kind of barbaric treatment was immortalized in the 1975 film One Flew Over the Cuckoo's Nest. The image of Jack Nicholson uncontrollably thrashing about in agony during electroshock treatments has probably done more to stigmatize ECT than anything else, and it continues to plague the therapy even today. "The way ECT is portrayed -- with people shaking, breaking bones, breaking teeth, and biting their tongues -- that's just not true anymore," says Dr. Omar S. Manejwala, a psychiatrist at Carolinas HealthCare System, who treats about three to five patients a day with ECT. "It's a life-saving procedure that helps combat depression that has really suffered from media misinformation."

By the early 80s, new and improved ECT machines were introduced that delivered less electricity in brief pulses, causing less cognitive damage.

"Older machines were constant voltage devices," says Manejwala. "They would allow you to set the voltage, and then the current would vary. It turns out we can spare memory better by keeping the current constant and allowing the voltage to vary."

As the new ECT technology grew more widely accepted, regulation and monitoring became an issue. Today, the law requires doctors to obtain "informed consent" from a patient before performing ECT, and it is the patient's right to accept or refuse treatment. If a patient's psychosis is deemed so severe that it impairs his ability to make an informed decision, the case must go to court where a legal guardian is appointed who then assists in making the decision.

ECT is generally recommended as a "second-line treatment," or in other words, a last resort. The exception to this is when there is a need for rapid, definitive response, or the patient, such as a pregnant woman, should avoid anti-depressant medications. A patient is typically given a series of six to 12 treatments administered two to three times a week to induce remission. A growing number of patients receive an intermittent schedule of continuation or maintenance ECT to prevent recurrence where medication therapies have proven ineffective.

"ECT has several advantages over medications," says Dr. Peter Rosenquist, an associate professor of psychiatry at the Wake Forest University School of Medicine, who has been using ECT since the late 80s. "When you get folks who have severe depression, or people who have depression with psychotic features -- delusions, hallucinations -- most medications just don't work very well, or they take six to eight weeks before they really kick in. With ECT people start feeling better after three or four treatments. So we have these treatment-resistant folks for whom ECT works when nothing else does.

As Brooks takes a few more deep breaths, the anesthetic and muscle relaxant kick in, and he drifts off into a twilight sleep. The doctor then delivers a pulse of electricity that passes between the two electrodes that have been placed on Brooks' temples. This charge penetrates Brooks' skull and scalp and enters his brain, which induces a seizure. Because he's been given a muscle relaxant, there are no marked contractions or convulsions, but nurses hold down each side of his body as a precaution. The pulse of electricity lasts about a second. The subsequent seizure lasts for approximately one minute. So what exactly is happening inside Brooks' head? And how does it help cure depression? The most basic answer is that the electrical charge induces a seizure, which stimulates the brain to release neurotransmitters -- chemicals like serotonin and dopamine -- that help combat depression. But beyond that, medical science still isn't sure how it works.

"As far as specifically saying this part of the brain changes in this exact way in all patients . . . that's not yet known," says Manejwala. "But we do know that the treatment is not effective unless an appropriate amount of current is used and a seizure occurs."

So just how much juice are we talking about?

"We've done studies to figure out how much electricity is necessary to pass through the brain to cause a seizure, and that's individualized," says Rosenquist. "Everybody has a different threshold."

Rosenquist explains that if you administer just enough juice to cause the patient's muscles to jump a little bit, then you're below the seizure level and the patient won't improve. Moreover, if you stimulate right at that seizure threshold, the patient's response rate will go down.

In order to find the appropriate voltage, doctors now do what is called a stimulus titration, which is a technique used to ensure each patient gets the minimum amount of energy necessary to produce an effective seizure. In the old days, doctors would just pick an energy level or use the maximum.

Despite its many advances, ECT remains of one of today's most controversial treatments. Richard Glass, editor of the Journal of the American Medical Association (JAMA) wrote in 2001 that ECT "is effective, safe, and no longer abused," but critics still abound."It is disturbing that such a respected source as JAMA sees fit to describe ECT as `an effective and safe treatment,' given the fact that a significant number of people have been permanently disabled by it," says Joseph A. Rogers, executive director of the National Mental Health Consumers' Self-Help Clearinghouse in Philadelphia.

"There is no medical, moral, or legal justification for ECT," writes freelance journalist Juli Lawrence, who received ECT in 1994 for severe depression, and started her own website www.ect.org the following year. Lawrence says that while her depression improved briefly after receiving ECT, she quickly slipped into an even worse depression than before, and it left her with severe memory loss.

"It took me a year to emerge from the fog that resulted from the ECT," Lawrence writes. "And it's taken six years to recover to the point that I am able to fully articulate what has happened. Day by day, I grow more convinced that ECT is not an effective treatment, and that it does little more than provide a brief respite from depression, followed by despair and hopelessness, and potential damage to the brain."

Other criticisms include a 2003 review in the British Medical Journal, which reported that one-third of ECT patients describe persistent memory loss. In the United States, the National Mental Health Association recommends ECT be presented to patients "with extreme caution" as a last resort. And The National Council on Disability described ECT as "unproven and inherently inhumane" and called for its elimination. Today, nearly all states have bills establishing, in some form, the right to refuse ECT.

Yet another study -- this one community hospitals in New York City, Westchester and Nassau counties conducted in 1997 -- found that 11 percent of patients were treated with outmoded ECT machines. Moreover, state regulators in New York said they did not know where the antiquated machines were, or even how many people receive ECT treatment throughout New York in any given year.

Doctors say this is not an issue in Charlotte. "It's been a long time since I've heard of anyone doing ECT with the old sine wave machine," says Manejwala. "But when I was in Brazil three years ago on vacation I met with some psychiatrists who couldn't afford a brief-pulse machine so they were doing it down there. However, there are no sine-wave machines used in Charlotte. Our machines are all state of the art."

However, Manejwala does add that there are no specific federal or state regulations that govern who can and cannot administer ECT other than that they have to be a licensed physician.

"ECT is not really "unregulated,' but it tends to be regulated at a more local level," Manejwala says. "For example, CMC has rigid requirements regarding psychiatric training and ECT experience before ECT can be administered. At CMC many of our psychiatrists are not privileged to do ECT and therefore they don't. The few of us who have the specialized training do the treatments."

After about 15 minutes, as the anesthetic medication wears off, Brooks awakens. He has no memory of the procedure, but is feeling its effects. "Have you ever run till you just felt like you can't take another step? That's the best way I know how to describe how I feel," he says. "And that lasts for at least 24 hours."

Brooks is led to the recovery room where he rests for about an hour; his wife then drives him back home to Union County.

Before Brooks started ECT, he was informed of its possible side effects, which include headache, jaw pain, muscle soreness, and nausea. Long-term side effects include memory loss and difficulty learning new information. The degree of memory problems is often related to the number and type of treatments given. A smaller number of treatments are likely to produce less memory difficulty than a larger number. Brooks says that he's suffered from none of these, other than "just being tired and worn out."

As with any procedure using general anesthesia, there is a remote possibility of death from ECT (estimated to be about 1 in 10,000 patients.) This rate may be higher in patients with severe medical conditions. And some people, like heart attack victims, those with uncontrolled high-blood pressure or a previous brain injury, are advised not to receive ECT. Moreover, doctors make it clear that while ECT is expected to improve or even cure your illness, symptoms may return. How long you will remain well cannot be known ahead of time. To make the return of symptoms less likely after ECT, patients are informed they will need additional treatment with medication, psychotherapy, and/or ECT.

"Once a patient becomes better, we then make a decision with them about using maintenance ECT once a month or a few times a year," says Manejwala. "Some just stick with medication to prevent symptoms from returning."

Brooks received his 20th ECT treatment earlier this month. He continues to take a small dose of anti-depressants, and will probably continue with ECT maintenance treatments every three months or so.

Brooks lives within 500 feet of where he was raised in Union County near Locust. He's been a turkey farmer all his life, and has been married to the same woman for 50 years. His daughter is principal of a nearby school, and his son recently graduated high school and is talking about joining the family business. Brooks could certainly use the help.

"We've got turkeys to raise, cattle to tend to, acres of corn and soybean . . . there's always work to be done."

So how does he feel today compared to when he went into the hospital nearly five months ago for his first treatment?

"It's as much difference as day and night," he says. "I wouldn't go back to the way I was for a million dollars. It really is like a miracle from God. I've got too much going on here to let my mind go out of whack and stop me from working."

Contact Sam Boykin at sam.boykin@cln.com or 704-944-3623.