If there were an award for perseverance, Hannah Wyatt Sultan, 28, would have earned it long ago.
Hannah has had anxiety since her early teenage years, depression since college and ADHD and PTSD on top of her other mental health challenges. Over the years, she has tried dozens of medications and sought help from multiple psychiatrists, including one who told her to “pick one illness she could live with.” She incorrectly told her that there were no solutions for all of her illnesses.
At one point, when an antidepressant she had been prescribed suddenly stopped working, she turned to her doctor, only to learn the doctor had retired. Not knowing where else to find help, Hannah headed to a hospital emergency room, where her experience was anything but pleasant.
“The attending physician actually accused me of being a ‘drug seeker,’” Hannah said. “I hadn’t even asked for drugs; I just genuinely did not know how to get help in a timely fashion, and the psychiatric emergency room is what was recommended to me, plus it made sense. I was having a mental health emergency.”
Despite difficulty in finding help, Hannah never gave up and perseverance paid off.
Today, she radiates joy and is passionate about bringing hope to other young adults. In her quest to find help, Hannah found an article about electroconvulsive therapy and the UCHealth Refractory Depression Clinic at Longs Peak Hospital. A few days later, she met with Dr. Konoy Mandal, a psychiatrist and medication director of the clinic in Longmont.
“Hannah was raring to get better and was just stuck — so stuck,” said Mandal. “Which is unbelievable if you were to meet her now.”
Needing help with mental health challenges
On the outside, observers may have always seen Hannah as a healthy, self-confident young woman. On the inside, she battled demons. While she always appeared to be the “well-behaved” achiever who did well in school, anxiety and self doubt crippled her on the inside. To make matters worse, as a young adult, Hannah fell into an abusive relationship which contributed to her growing depression.
As a young woman, Hannah had many days when she couldn’t sleep and other days she couldn’t get out of bed. Depression prevented her from fulfilling obligations, enjoying life, and she found herself avoiding leaving her home because she was “just too exhausted and too sad.”
“While not every moment of my life was utter misery, the unpredictability of the severity of my depression symptoms and having to cope with the side effects of my medications became completely debilitating,” Hannah said.
Being honest in love when you’re dealing with a mental illness
Hannah wasn’t looking for love after leaving the abusive relationship, but it found her anyway. She started dating Lukas, an engineering student and now her husband of three years, in November 2013. Just months later, in April 2014, she was doing poorly mentally. She made the difficult decision to take a medical leave of absence from the University of Arizona and headed home to Augusta, Georgia, to seek treatment from the comfort and security of her parents’ home.
Hannah’s mother also struggles with depression, though Hannah grew up knowing what a supportive relationship looked like. Her father has always been “a rock’’ for her mom. From the start, Hannah had been honest with Lukas about her mental health issues. And when she has in-depth conversations with him, he accepts her for who she is.
“I couldn’t believe that someone with minimal knowledge of mental health issues and extremely limited interactions with people with diagnosed mental illnesses could be so compassionate and understanding. It still amazes me all these years later,” Hannah said.
By the fall of 2014, Hannah was able to return to the University of Arizona to complete her undergraduate education. She graduated in December 2015 with a Bachelor of Science in Care, Health, and Society.
Navigating health care with a mental illness
In September 2017, she moved with Lukas to Denver. Despite her illness, she enrolled in undergraduate science courses and was accepted into an accelerated one-year Bachelor of Nursing program. When her medications suddenly stopped working, Hannah took a medical leave of absence. She re-enrolled in 2020, and despite earning good grades and loving nursing, depression (coupled this time with chronic migraines) stood in her way. Right after the coronavirus pandemic began, Hannah again discontinued her nursing education.
“I was completely heartbroken for so many reasons, but I think the greatest source of anguish for me was that I wasn’t moving forward with life like I knew I could if I didn’t have such severe depression,” Hannah said. “So I started looking for different options. At that time, I didn’t even know remission (from depression) was possible, especially for someone like me.”
While in nursing school, Hannah heard about electroconvulsive therapy, or ECT, through a fellow student and friend.
Several months later she found an article about ECT in Colorado, and then Hannah met with Mandal and his staff.
“Dr. Mandal understood that what I had gone through was wrong. He told me it was not my fault that other treatment efforts had failed, and he wished I had been referred to ECT way before finding him on my own,” Hannah said. “He said there was no award for suffering. If there were one, I would have won.”
Medications don’t always work for mental health issues
Mandal said research is clear that people experiencing mental health issues often experience treatment resistance after three novel treatments. By the time a patient tries a fourth medication, there’s only a 7-to-10% chance that it will work.
“It’s understandable to keep fighting for something that will help,” Mandal said. “But once you’ve exhausted that track with medication, you need to look at neuromodulation therapies.”
Unlike medications that run through the entire body, neuromodulation therapies deliver electrical or pharmaceutical agents directly to a target nerve area in the brain. These therapies, such as Ketamine, deep-brain stimulation and ECT, aggressively change how specific neurons interact with other neurons, Mandal said.
ECT is an option for any “reversible short circuit in the brain, which is any mood disorder,” he said. It does not work for “hardwire” illnesses, such as multiple sclerosis, dementia or strokes because in such illnesses, “the wires themselves are problematic, not the fuse box.” These fuse box, or short-circuit conditions include psychotic disorders, hallucination-based disorders, migraines, epilepsy and Parkinson’s.
Starting electroconvulsive therapy (ECT) for depression
Hannah first met Dr. Mandal on a Thursday.
“I appreciated (Dr. Mandal’s) sense of humor because that is very much me,” Hannah said. “I try to keep things light. It’s part of my internal coping mechanism. But it’s also my personality. The combination of getting along well with Dr. Mandal, and the knowledge that he was more qualified and more experienced with what I was dealing with than anyone I had seen before, gave me a sense of trust in my psychiatrist that I had never experienced, and, in my opinion, is a big part of the reason this has all turned out so well.”
The following Monday, Nov. 9, 2020, she was back at the clinic for her first treatment.
ECT only takes about three minutes, but the appointment takes about two hours because nurses have to prep the patient for the procedure. ECT emits electrical pulses throughout the brain, so patients are under general anesthesia, hooked up to an IV and monitored afterward.
“When I initially decided to go for ECT, I really didn’t have any hesitancy, I just wanted to get better,” Hannah said. “But as my nurses were prepping me, I became increasingly nervous. As I was about to go under for the first time, I began to cry because I was so fearful. I will never forget asking my nurse, Jason, if I could hold his hand, and with absolutely zero hesitation, he grabbed my hand and reminded me that everything was going to be alright. The rest is history.”
Doctors use different ECT protocols for different patients. Hannah received outpatient ECT three days a week for three weeks, then two days a week for three weeks, followed by once a week for four weeks.
Hannah started to notice changes within the first week.
“It was shocking — pun intended — how well it worked,” she said. “I was feeling dramatically better after my second treatment, which Dr. Mandal said was a really good sign that this treatment would work well for me and my depression.”
Why does ECT work for depression, other mental health conditions
“ECT is one of the most evidence-based interventions available to get a client into remission,” Mandal said. “Remission is not only feeling better. It is being indistinguishable from someone who does not have an illness. It is not a cure but total control of the illness. No other treatment in psychiatry has better data to return a person to their pre-illness functioning.”
ECT works in the same way a defibrillator or pacemaker helps restore a normal rhythm to a person’s heart, he said. Heart heart arrhythmia occurs when electrical signals that coordinate heartbeats beats don’t work correctly, mental illness occurs when electrical signals in the brain don’t function properly.
“It’s not that the healthy wires aren’t there, it’s just that electricity is not going through the wires for whatever reason,” Mandal said.
ECT has excellent results for those over age 65 but has “amazing data for younger people too,” Mandal said.
He explained that the more genetic loading a person has of a specific illness — meaning a strong family history — the earlier in life the condition will appear for that person. ECT data shows high remission rates for people in their 20s, setting them on a positive course for the rest of their life by significantly decreasing the likelihood they’ll ever have to deal with that illness again.
What are the side effects of ECT?
Hannah could have terminated her treatment plan at any time had the side effects been too much.
Mostly, she had “ECT brain,” which is expected during the early stages of treatment. The first few weeks, she would walk into a room and forget what she was going there to do. Her photographic memory was not affected, and the benefits far outweighed the short-term, temporary memory loss.
After the first week, Hannah no longer slept until noon.
“Many positive changes were happening, but I was distracted having to go to the hospital so often,” she said.
ECT is a time commitment. Dr. Mandel met with Hannah and Lukas prior to her treatment, and Lukas accompanied his wife to her appointments and her mother also came to appointments. Hannah said that support was vital to her success.
As her ECT appointments tapered off, Hannah said she was faced with a new reality.
“I had forgotten what it was like to feel normal,” she said.
With her energy and drive back, her high-achieving personality flourished, and she had to figure out how to manage life without depression. A decade of depression and anxiety had impeded her career goals.
Luckily, Mandal doesn’t prescribe ECT by itself.
ECT is part of a whole-body treatment plan toward remission
Along with the ECT schedule, Mandal works with patients to develop an exercise and psychotherapy plan. With this combination, patients have an 80% chance of staying in remission years after ECT, Mandal said.
“It’s like the mind is a garden with tons of weeds,” he explained. “ECT clears the weeds, it tills, it brings the water and all of that, but it doesn’t plant anything. ECT is only as good as the therapy that follows it. That’s where patients make enduring changes in their brain.”
Talk therapy is proven to be the best intervention to rewire the brain. The problem, Mandal explained, is that a person’s brain needs to be functioning well for talk therapy to work.
“If a person has severe depression, there is not a lot of electricity in the frontal lobe, which is what we use to retrieve memories, put things together with meaning, and understand vocal inflections,” he said. “When you have a severe illness, you can’t do any of that. You can give a person all the talk therapy you want, but they cannot do anything with it. They will just be stuck in therapy for years. That’s where ECT comes in. It gets you out of that cycle. ECT builds that engine and talk therapy pushes on the gas pedal.”
Hannah continues to meet with Mandal for medication management. She also sees a talk therapist.
Her advice to others is to seek help.
“It takes courage to try anything in regards to addressing one’s mental health,” Hannah said. “It was possible (ECT) wouldn’t work, but I had to be willing to try, to have the courage to try. I think no matter what it is, whether it’s starting to talk to a therapist, getting on antidepressants, or going as far as doing ECT, we shouldn’t discount the courage that it takes to be vulnerable and ask for help.
“I think it also takes great bravery not to become discouraged if that help doesn’t do what we as individuals had hoped it would and to be willing to try again if necessary.”
Hannah can now move forward. “I’m looking into the next steps of life. What can I be successful at, and what can I do to be helpful to others?” she said.
She is still considering a career in health care, using her experience as motivation for helping others and making a difference. She hopes her perseverance and openness about her experiences will help others believe in themselves.
“If you think you’re not feeling well, talk to someone. If you know you’re not well, speak to someone. Please, do it because you are amazing. There is only one of each of us.
“Find the person willing to help you; find the doctor who will help you be the best you. Don’t suffer. Keep trying. Don’t give up on yourself. And encourage one another to fight for remission because it is possible.”