Edward Shorter, PhD

[[{"type":"media","view_mode":"media_crop","fid":"33167","attributes":{"alt":"Improving Mental Health","class":"media-image media-image-right","id":"media_crop_121289892088","media_crop_h":"216","media_crop_image_style":"-1","media_crop_instance":"3490","media_crop_rotate":"0","media_crop_scale_h":"125","media_crop_scale_w":"200","media_crop_w":"346","media_crop_x":"4","media_crop_y":"27","style":"float: right; margin-top: 1px; margin-bottom: 1px;","title":" ","typeof":"foaf:Image"}}]]In psychiatry, there has been rising unhappiness over DSM, over the lack of progress in the development of psychopharmaceuticals, and over the field’s ongoing inability to establish itself as a neuroscience, despite the pages and pages of dense tables that appear in the 

. What is needed are new disease entities, new therapeutic ideas, and a new approach to what one might, with only slight pretentiousness, call “psychiatric theory.” A few practical suggestions follow that might take us a bit further down the road to these goals.

Use the medical model, not the “biopsychosocial model,” to delineate diseases in psychiatry. This means a careful psychopathological clinical description of disease entities, separating them from other disorders; their verification with biological tests; and their validation with a specific response to treatment.

 at Washington University in St Louis first proposed this in 1970 as a way forward for psychiatry. The field has now made a stab at this by delimiting the symptoms of melancholia; verifying the distinctiveness of the disease with a biomarker in the dexamethasone suppression test; and validating its treatment with electroconvulsive therapy (ECT).

 One hopes for further progress in this direction.

Break the “Kraepelinian grip” on diagnosis by abolishing the firewall Kraepelin erected in 1899 between mood disorders and chronic psychosis. Parts of Kraepelin’s great synthesis remain standing (or should do so), such as delineating “adolescent insanity” (dementia praecox) as a separate form of psychosis and calling attention to manic-depressive insanity as a disease basin of its own, including all forms of serious depression and mania.

 But Kraepelin erred in erecting a firewall between the two, for there is a huge overlap. Ignoring the overlap persuades us that adolescent insanity must be treated with antipsychotics and manic-depressive symptoms must be treated with antidepressants, a guarantee of polypharmacy.

On the other hand, restore the Kraepelinian unity of mood disorders by lumping major depression, bipolar disorder, and the manias into the same pot, which, following Bernard Carroll’s

 suggestion, we will now call “Kraepelin disease.” (There will be much psychosis in this pot, since we have abolished the firewall.)

Complete the liberation of catatonia as an independent disease entity by calling it “Fink disease” after Max Fink, who fought against great odds to have catatonia removed as a “subtype” of schizophrenia and be given a home of its own. This exemplifies the medical model in action: delimiting the exact symptoms of catatonia, as DSM-5 has recently done; verifying it as a stand-alone disease state with a benzodiazepine challenge; and validating its response to treatment with lorazepam and ECT.

Take the classification of disease away from the American Psychiatric Association (APA) and DSM, and give it to an independent agency, such as the Karolinska Institute or the NIMH, for a completely new beginning. (The World Health Organization would not be a candidate for this mission, since its ICD has now been largely corrupted by DSM.) DSM has been a rolling disaster. DSM-III in 1980, under the leadership of Robert Spitzer, was a step forward in releasing the clench of psychoanalysis upon the field.

But later editions have preserved many of the errors-eg, mechanically reproducing such artifacts as “major depression,” which lumps together the two very distinct depressions that psychiatry has always had: melancholia and nonmelancholia, also called neurasthenia, reactive depression, and so forth. Gordon Parker

 resurrected melancholia in 1996 as a distinctive disease entity. Yet the gates of DSM have remained firmly shut to this venerable wanderer. (In DSM-5, it is dismissed as a “specifier,” and it is not even mentioned in the index.)

Abolish psychoanalysis from the psychotherapy training of residents. (It is like making a course in astrology requisite for the training of astronomers.) DSM-III in 1980 represented the historic Waterloo of psychoanalysis. Thereafter, general psychiatry quickly lost confidence in Freud’s wisdom, although the field’s current absolute trust in neurotransmitters seems equally misplaced. Yet even today, at the field’s commanding heights, a few demoralized analysts continued to hold forth and to impose a knowledge of depth psychiatry, familiarity with the “unconscious,” and so forth as requirements for training. This atavism is as absurd as the persistence of witchcraft, and it must be brought to an end.

Vastly increase the psychopathology content of residents’ training. Although the study of psychopathology is still alive and well in Scandinavia and Germany, it seems to have largely come to an end in North America, replaced with the “operative criteria” of DSM. Yet only a fine understanding of signs and symptoms gives clinicians the wherewithal to break down these huge, heterogeneous basins of DSM (eg, major depression, schizophrenia) into distinctive disease entities that might have differential responses to treatment and prognoses.

There is no pharma conspiracy to rivet these vast DSM constructs in place-although they do make convenient pharmaceutical markets. What retains them is mainly the determination of the APA not to further introduce large changes in the field’s classification of disorders. Yet it is as though medicine, “to avoid confusion,” had insisted on retaining Galen’s classification of chest diseases. It would be wonderful if genetics were to point the way to a truly scientific classification in the future. But genetics will not be able to do that in the absence of scientifically based phenotypes, and that is what we now need.

Firm up cross-training between psychiatry and neurology, so that “clinical neuroscience” ceases to be dominated by neurology, and psychiatry gets another shot at being scientific. At the moment, there is little dialogue between the two disciplines: If one mentions to a neurologist that there might be a role for convulsive therapy in the management of parkinsonism, the response is an incredulous stare.

Neurologists simply have not been exposed to this considerable advance. And neurologists express surprise at psychiatry’s studied indifference to the EEG in the diagnosis of anything except epilepsy (not a psychiatric disease in any event).

 There have, in other words, been big doings on both sides of the fence, but it is as though the fence were 9 feet tall and painted black.

End the hysteria about not accepting ballpoint pens and the like from industry on the grounds that such tokens will bias clinical judgment. Psychiatry is subject to fads, and of the fads none is more exasperating than this sissy sanctimony about not being corrupted by “Big Pharma.” Guess what? Big Pharma has already hopelessly corrupted the field by promoting these unscientific DSM diagnoses!

“Major depression” and “general anxiety disorder” have made billions of dollars in profit for the pharmaceutical industry. Industry is not interested in corrupting the field by giving out pens or neat little desk clocks. It’s too late for that! And what is so irritating is not just the belief that free penknives will sway us, but the belief that in barring them we have safeguarded ourselves from pharmaceutical influencing. You have to be living on cloud 9 to believe this.

Restore the history of psychiatry to a prominent place in the postgraduate curriculum (and in the leisure reading of practitioners), because it is historical wisdom that tells us how fragile are our diagnoses today, how inadequate our treatments. Psychiatry goes back 2 centuries, and over that span a lot of knowledge has accumulated about diagnosis and, even in the early days of psychopharmaceuticals (the 1920s to the 1940s), about treatment. Delirious mania as a diagnosis, amphetamine as a treatment for anything other than rest-less male adolescents: all forgotten. Yet there’s gold in them thar hills. When the field’s main diagnoses are major depression and schizophrenia, its main treatments Prozac and the “SGAs” (second-generation antipsychotics), it is time to bring in the historians!

 Robins E, Guze SB. Establishment of diagnostic validity in psychiatric illness: its application to schizophrenia. 

Endocrine Psychiatry: Solving the Riddle of Melancholia

. New York: Oxford University Press; 2010.

What Psychiatry Left Out of the DSM-5: Historical Mental Disorders Today

 The Neurocritic. Carroll’s comment of August 5, 2013. http://neurocritic.blogspot.com/2013/08/breakthroughs-in-bipolar-treatment.html. Accessed January 29, 2015.

 Fink M. Rediscovering catatonia: the biography of a treatable syndrome. 

Melancholia: A Disorder of Movement and Mood

. Cambridge, UK: Cambridge University Press; 1996.

 Pintor LP, Valldeoriola F, FernÃ¡ndez-Egea E, et al. Use of electroconvulsive therapy in Parkinson disease with residual axial symptoms partially unresponsive to L-dopa: a pilot study.

 McLoughlin G, Makeig S, Tsuang MT. In search of biomarkers in psychiatry: EEG-based measures of brain function. 

Articles

What psychiatry needs is a new approach to “psychiatric theory.” Here are a few practical suggestions. 

Improving the Mental Health System by Addressing Core Problems

A Hollywood movie almost killed an important psychiatric treatment. After clinicians and members of the public saw the film 

, which premiered in 1975, many swore “never again.” The fantasy bore no relationship to the actual conduct of an effective psychiatric treatment, yet almost wrote its death warrant.

Years later we are still dealing with the fallout from that fantasy. Although many clinicians have accepted ECT, the public harbors the image of Jack Nicholson being forcibly subjected to treatment without his informed consent, and they do not wish this for one of their family members. As a consequence, serious cases of depression, mania, and catatonia-unresolved by medications and psychotherapies-are haphazardly denied evidence-based treatment.

The effective component of the treatment is the cerebral seizure itself and not the electricity. There are other ways of eliciting seizures, however, without putting electrodes on fearful patients. Flurothyl, an anesthetic, offers an effective treatment by inhalation or by infusion.

Chemical infusions to treat MDD began in the late 1950s, as soon as the antidepressant efficacy of oral imipramine was recognized. Rapid relief was temporary, and adverse effects of dry mouth and skin, increased heart rate, and impaired vision deterred its use. In 1982, the Swiss psychiatrist Paul Kielholz optimistically reviewed infusion therapy with an emphasis on the antidepressants clomipramine and maprotiline.

 Brightening of mood occurred but was transient, and the procedure was discarded. Recently, infusions of the anesthetic ketamine have been tested but, again, the benefits are short-lived.

Studies from the 1930s found minimal concentrations of brain glia in those who died with schizophrenia and a surfeit in those with epilepsy.

 A concept of an antagonism between these disorders encouraged the search for ways to safely induce seizures. Introduced in 1934, intramuscular injections of camphor were successful, but dosing was difficult and the delay to seizure was worrisome. Many injections failed to elicit a seizure. Intravenous pentylenetetrazol (Metrazol) was tested the same year and quickly adopted because of its greater efficiency. By 1938, the induction of seizures by electricity was found to be more efficient, giving rise to the worldwide use of ECT.

In 1957, an alternative seizure-inducing agent, flurothyl (Indoklon), a congener of the inhalant anesthetic diethyl ether, was tested.

 With a few inhalations consciousness was lost, and with a few more the electroencephalogram (EEG) showed the slow waves and spikes characteristic of a seizure. Extensive clinical experiences and 4 well-documented controlled trials comparing flurothyl with ECT reported that from 3 to 10 inhalations over a few weeks successfully relieved severe depression and psychosis.

Durations of the EEG seizure were longer and the effects on cognition and memory were less with flurothyl than with ECT. Motor movements accompanied the EEG seizures, and as in modified ECT, they were readily blocked by pretreatment with succinylcholine. Neither spontaneous tardive seizures nor missed treatments were reported. Pharmacological studies found no systemic toxicity.

Yet, flurothyl infusions were discarded, not because of inefficacy or adverse effects but because of fears among clinicians who administered the therapy and breathed the exhaled anesthetic that gave the treatment room a characteristic pungent ethereal aroma. The discarding of this treatment, with its relative lack of adverse effects and considerable benefit, was an error.

The most effective treatment for medication-resistant mood disorders today is ECT; the principal deterrent to its use is the widespread fear of loss of memories. To be sure, in the flurothyl and ECT trials, mild and transitory cognitive impairment was noted during the acute phase. With flurothyl, however, the therapeutic effects were greater, observed earlier, and persisted longer than with ECT. In addition, flurothyl avoided the direct effects of electricity on brain function above and beyond the seizure.

Many efforts have been made to reduce the impact of electric currents on brain function. The form of the current, dosing, placements of electrodes, frequency of seizures, and replacement of electricity by magnetic currents have occupied clinicians and researchers for decades.

 Progress has been made, but public fears have not been allayed.

Flurothyl is a unique and rapidly effective anesthetic that has a favorable therapeutic balance. Safe air handling of inhalant anesthetics has been resolved and the fears that inhibited the use of flurothyl are no longer an issue. Seizure management, and control of motor effects and systemic cardiac risks are no longer deterrents to seizure induction with flurothyl.

Much has been learned about the neuroendocrine abnormalities in hypothalamic, pituitary, adrenal, and thyroid functions that accompany mood disorders. Each seizure elicits an outpouring of endocrine peptides. With repeated seizures, the hormone irregularities are redressed and the abnormal mood syndrome relieved. The mechanism of the relief is not known, but the effect is extensively documented.

A reexamination of flurothyl infusions holds promise for improved resolution of severe mood disorders, as well as for a greater understanding of the mechanism of their pathophysiology. A reassessment of the flurothyl experience using present-day anesthesia facilities is encouraged.

Acknowledgement-We are indebted to Kathryn Cooper, BS, Class of 2016 of the University of Rochester School of Medicine in New York for a detailed review of the clinical experience with chemical inductions of seizures in man.

Dr Fink is Professor of Psychiatry and Neurology Emeritus, Stony Brook University School of Medicine, NY. Dr Shorter is Jason A. Hannah Chair in the History of Medicine, Faculty of Medicine, University of Toronto, Ontario, Canada. They report no conflicts of interest concerning the subject matter of this article.

 Cooper K, Fink M. The chemical induction of seizures in psychiatric therapy: were Flurothyl and Metrazol abandoned prematurely? 

 Murrough JW, Iosifescu DV, Chang LC, et al. Antidepressant efficacy of ketamine in treatment-resistant major depression: a two-site randomized controlled trial. 

 Meduna L. Autobiography of L. J. Meduna. 

Shock Therapy: A History of Electroconvulsive Therapy in Mental Illness

. New Brunswick, NJ: Rutgers University Press; 2007.

 Kurlan AA, Hanlon TE, Esquibel AJ, et al. A comparative study of hexafluorodiethyl ether (Indoklon) and electroconvulsive therapy. 

 Fink M, Kahn RL, Karp E, et al. Inhalant-induced convulsions: significance for the theory of the convulsive therapy process.

 Small JG, Small IF, Sharply P, Moore DF. A double-blind comparative evaluation of flurothyl and ECT. 

 Laurell B. Flurothyl convulsive therapy. 

 Fink M. What was learned: studies by the Consortium for Research in ECT (CORE) 1997-2011. 

A reexamination of flurothyl infusions holds promise for improved resolution of severe mood disorders, as well as for a greater understanding of the mechanism of their pathophysiology.

Revive Flurothyl Inhalation Therapy

Following the success in 1917 of Vienna psychiatry professor Julius Wagner von Jauregg, M.D.'s, malarial-fever treatment of neurosyphilis, there was great interest in using such "physical therapies" for other neuropsychiatric illnesses as well. It was in this context of enthusiasm for treating the brain itself in mental illness on the model of neurosyphilis--rather than relying upon the resources of psychotherapy--that the convulsive therapies arose (Shorter, 1997).

Over the years these therapies--the mechanisms of which even today are unknown--have demonstrated considerable efficacy in the treatment of major depression, catatonia, mania, psychosis and other psychiatric disorders. An impressive body of opinion now holds that electroconvulsive therapy has such a demonstrated record of efficacy that it, rather than medication, should be the treatment of choice in major depression. The real question today is: Why is it not? Why does the idea of applying ECT still cause a chill among many psychiatrists and patients, who consider it only as a treatment of last resource, rather than the first-line approach? 

The first of the convulsive therapies was initiated in 1934 in Budapest, Hungary. It entailed inducing convulsions with pentylenetetrazol, a compound first introduced as a cardiac drug and sold under the trade name Cardiazol in Europe and Metrazol in the United States. Psychiatrist Ladislas von Meduna, M.D., hypothesizing an antagonism between epilepsy and schizophrenia, reasoned that chemically inducing convulsions might somehow meliorate the psychotic symptoms of schizophrenia. He first tried camphor, then pentylenetetrazol, which was more soluble and acted faster (Fink, 1985). In fact, he achieved considerable results, and treatment units sprang up before World War II at a number of centers in Europe. In the United States, such disparate institutions as the Georgia state asylum at Milledgeville and the Sheppard-Pratt private clinic in Baltimore installed Metrazol units.

Yet, Meduna's convulsive treatment was quickly pushed to the margins by ECT, initiated in 1938. In one of the few Italian contributions to modern psychiatry, psychiatry professor Ugo Cerletti, M.D., inspired by the successful treatment of a rapidly accumulating list of physical disorders (including fever, deep sleep and insulin coma) resolved to induce convulsions by applying electricity directly to the brain. Like Meduna, he and his assistant Lucio Bini selected patients with schizophrenia for their trials and enjoyed a record of success (Cerletti, 1950). Their publications created a major stir in psychiatry, and in May of 1940, Cincinnati psychiatrist Douglas Goldman, M.D., demonstrated ECT at the annual meeting of the American Psychiatric Association (Shorter, 1997). 

Electroconvulsive therapy spread quickly in popularity, and handbooks were not long in appearing. In 1941, Lucie Jessner, M.D., at Massachusetts General Hospital and V. Gerard Ryan, M.D., at Harvard University published 

, the introduction written by Harry Solomon, M.D., chief of research at the then Boston Psychopathic Hospital (later Massachusetts Mental Health Center). In 1944, William Sargant, M.D., and Eliot Slater, M.D., at The Maudsley Hospital in London, themselves noted figures in English psychiatry, brought out 

An Introduction to Physical Methods of Treatment in Psychiatry

. In 1946, Lothar Kalinowsky, M.D., who was instrumental in bringing ECT to the United States, and Paul Hoch both wrote the influential book 

Shock Treatment and Other Somatic Procedures in Psychiatry

. Thus, major figures weighed in on behalf of the new treatment.

The U.S. military made wide use of ECT during World War II, and by the 1950s, ECT had become one of the standard treatments for hospital depression, accepted as a matter of course in U.S. and European psychiatry. 

The rise of ECT in psychiatry is one of the discipline's great success stories. The technique became steadily modified. In 1940, curare was introduced to moderate the vertebrae-cracking force of the convulsions, and succinylcholine was introduced in 1952. In the early 1940s, it became customary to anaesthetize patients with barbiturate injections. In 1949, Goldman introduced unilateral ECT, placing the electrode over the right hemisphere in order to avoid the speech areas. Abrams and Taylor (1976) introduced bifrontal ECT by moving the electrodes forward over the forehead. In the 1950s, a patient hospitalized for depression stood an excellent chance of receiving ECT, and an even better chance of benefiting from it.

Then suddenly, a page turned, and ECT disappeared from psychiatry. In psychiatric training from 1960 to about 1980, ECT virtually vanished. Why this sudden disappearance of a safe and effective therapy occurred is one of the riddles of the history of psychiatry. 

It is not that the growing power of the pharmaceutical industry marginalized ECT. In the early days, industry executives and scientists often had a kind word for ECT. The Geigy company (now folded into Novartis) once conceded that ECT was the appropriate treatment for hospital depression, and Paul Janssen, of the pharmaceutical company founded by his family, had no hesitation in declaring that ECT was far superior for endogenous depression to the tricyclic antidepressants (Healy, 1998). Of course, industry's attitude would later change as ECT was excluded from discussion at industry-sponsored events. Yet the opposition of industry does not explain the bizarre initial vanishing of ECT for two decades.

Nor is it the case that psychoanalysis, based on a totally different model of brain-mind function, chased ECT from the temple. In the late 1940s and early 1950s, plenty of analysts were ready to mix ECT with talk therapy. The early group therapists, for example, would alternate between community sessions and ECT. Psychoanalysis pioneer Sandor Ferenczi was said to have administered ECT during analytic sessions.

What seems to have happened was a combination of 1960s-style counterculture hostility to ECT together with the enthusiastic reception of Ken Kesey's antipsychiatry novel One Flew Over the Cuckoo's Nest, published in 1962. There is no doubt that the generation of flower children was hostile to psychiatry in general and to ECT in particular. Sociologist Erving Goffman's influential work Asylums, published in 1961, bore a scanting reference to "shock treatment." Yet, the 1960s antipsychiatry literature was written largely for intellectuals. Furthermore, the systematic campaign of the Church of Scientology against ECT in those days had trouble gaining traction.

It was Milos Forman's 1975 film version of Ken Kesey's novel that had a shock effect on the public. Both the novel and the film mingled ECT and lobotomy together in a grisly depiction of what one would not want to happen if one fell into the clutches of psychiatry. The movie was United Artists' biggest hit ever at the time. 

The epicenter of public hostility to ECT was the 1970s and 1980s. Before the 1970s, virtually nothing was written in the popular press on ECT. Then a wave of attacks began between the mid-1970s and mid-1980s on the procedure, resulting in a 1974 law against ECT in California. In retrospect, it is actually quite breathtaking that a medical procedure of value to those suffering from a grave illness should have been outlawed out of concern to protect patients from the practice of psychiatry itself. 

The 1974 California legislation acted as a cold shower for the American Psychiatric Association. In 1975, the APA convened a working group on ECT that reported in 1978 (APA, 1978). The APA's report was a rather lukewarm endorsement of the practice, but it at least admitted a role for ECT. (This document was also the first in the history of psychiatry to demand informed consent from patients.) After long years of silence, the discipline's professional association had now uttered a rather feeble imprimatur.

The real turning point in the restoration of ECT was a consensus conference on the subject, organized by the Office of Medical Applications of Research of the National Institutes of Health. The background of this conference was the unremitting work of Max Fink, M.D., on behalf of ECT. Fink had started to practice ECT as a resident at New York's Bellevue Hospital in 1948, then shortly thereafter, took charge of the ECT unit at Hillside Hospital in Glen Oaks, N.Y. In 1979, Fink wrote 

, which marshaled data showing ECT more effective than antidepressant drugs. The NIH Consensus Conference on Electroconvulsive Therapy, a summary of which was published in 

 in October 1985, noted, "Not a single controlled study has shown another form of treatment to be superior to ECT in the short-term management of severe depressions." The consensus statement, issued by such dignitaries in the profession as Paula Clayton, M.D., and Allen Frances, M.D., and psychologists Kay Redfield Jamison, Ph.D., and Myrna Weissman, Ph.D., represented a definitive turn in the revival of ECT. 

Meanwhile, new guides to the procedure were in the offing. In 1979, Fink wrote the first ECT textbook for the generation that had sat on the sidelines. In 1988, Richard Abrams, M.D., published 

, a work that entered its 4th edition in 2002. In 1994, the APA offered Laurence B. Guttmacher, M.D.'s, 

Concise Guide to Psychopharmacology and Electroconvulsive Therapy

So why has ECT not been fully rehabilitated? Why was the New York Times able to run a front-page article on the treatment of depression without a single mention of ECT? Indeed, commenting on the fact that only a small percentage of general hospital inpatients with major depression receive ECT, an editorial by Harvard's Carl Salzman, M.D., in the January 1998 issue of the 

 expressed bewilderment that it was not more widely adopted. 

Electroconvulsive therapy had changed from being a first-line treatment of depression in the 1940s and 1950s to merely an approach to treatment-resistant depression in the 1990s. (Fink refers to "therapy-resistant depression" as a euphemism: It should be called, in his words, "inadequately treated" depression.) An article in the May 22, 2001, issue of 

 noted that the competence of young psychiatrists in ECT was falling. The likely reason: Few of their teachers, trained in the fallow period of 1960 to 1980, felt comfortable with it.

Finally, there is the firm but silent resolution of industry not to include ECT in drug trials, satellite symposia and industry-sponsored meetings. The logic seems clear to me: ECT would show superior efficacy to whatever they have to offer, and they prefer to keep it out of scientific discussion. I once, rather puckishly, asked a drug company to support a conference on ECT and received a scrawled handwritten reply from the head of psychopharmacology saying basically, "Are you kidding?" Requests from senior psychiatrists to include papers on ECT at industry-financed meetings are routinely refused.

Are there comparable examples in medical history of an important treatment suddenly disappearing for cultural reasons? Possibly the vaccination riots of the 19th century held back that treatment's progress for a bit. Yet, to put the downplaying of ECT in perspective: It is as though penicillin had entered a fallow period because of opposition from Christian Science, then experienced difficulty struggling back from the precipice, despite compelling clinical data. 

What accounts for the ongoing reluctance of a profession that now prides itself as having rejoined scientific medicine? The answer is that psychiatry remains infused with the kinds of cultural fears and prejudices that other specialties are able to insulate with the firewall of evidence-based medicine. The reality is that the culture we inhabit still fears ECT, just as many still fear vaccination. Clinicians are reluctant to recommend ECT to patients to avoid upsetting them with the fearsome words and thus break the therapeutic alliance.

Yet, we are not dealing with copper bands for rheumatism here. We are dealing with life-shattering illnesses, such as melancholic depression, mania and catatonia. A treatment of proven safety and reliability is within reach for them. It is madness not to use the full resources of scientific medicine.

 Abrams R, Taylor MA (1976), Diencephalic stimulation and the effects of ECT in endogenous depression. Br J Psychiatry 129(5):482-485.
 

 APA (1978), Electroconvulsive Therapy. Washington, D.C.: American Psychiatric Publishing Inc.
 

 Cerletti U (1950), Old and new information about electroshock. Am J Psychiatry 107:87-94.
 

 Fink M (1985), Historical Article: Autobiography of L.J. Meduna. Convulsive Ther 1(1):43-57.
 

 Healy D (1998), The Psychopharmacologists II. London: Lippincott Williams & Wilkins Publishers.
 

 Shorter E (1997), A History of Psychiatry: From the Era of the Asylum to the Age of Prozac. New York: John Wiley & Sons.

In looking at the history of ECT, it appeared to have been quite successful in treating a variety of psychiatric disorders. If that is the case, then why did it disappear from the "psychiatric map" for a number of years? What obstacles need to be overcome to return ECT to its place as a viable treatment option?

Edward Shorter, PhD

Articles

Improving the Mental Health System by Addressing Core Problems

Revive Flurothyl Inhalation Therapy

The History of ECT: Unsolved Mysteries