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is the Theodore J. Castele Professor of the History of Medicine and Associate Director of the Program in Medicine, Society, and Culture at Case Western Reserve University, Cleveland, Ohio. He holds secondary appointments in the Departments of Bioethics and Psychiatry. He earned degrees in history from Wesleyan (BA), Stanford (MA), and Johns Hopkins University (PhD); he also studied psychiatric epidemiology at Columbia University. He is the author of

 Imperial Bedlam: Institutions of Madness and Colonialism in Southwest Nigeria 

 Electroconvulsive Therapy in America: The Anatomy of a Medical Controversy 

 The Empire of Depression: A New History 

(Polity Books; 2020). His articles have appeared in journals including the

 Journal of the History of Medicine and Allied Sciences, Harvard Review of Psychiatry, Bulletin of the History of Medicine

Dr Sadowsky is a leading historian of psychiatry, and one I am proud to call him my teacher. As a psychiatry resident, I attended his lectures on history of psychiatry as part of our residency didactics and benefitted greatly from them. Sadowsky was 

 in 2017 by Greg Eghigian, PhD, about his book, 

Electroconvulsive Therapy in America: The Anatomy of a Medical Controversy

, an interview that is well worth revisiting. The present interview is about his new book 

. I admire Sadowsky for his ability to tackle complex and controversial issues with scholarly rigor and fair-minded appraisal, and I am delighted to have him participate in this series.

: I suppose some folks, on hearing the title of your new book, may reflexively think, “What…another book about depression? Don’t we have enough of those already?” In your opinion, why was a new history of depression needed?

: Interestingly, not many of the books about depression are histories. Take 

The Noonday Demon: An Atlas of Depression 

 I think it is great, but it has only a single chapter on history, and it is a brief account. In addition, with a few exceptions, most of the history books are focused on antidepressants, but many other treatments have important histories—psychodynamic psychotherapy, cognitive behavioral therapy (CBT), electroconvulsive therapy (ECT), and the many approaches that were taken prior to the 20th century, for example.

A couple of long, detailed histories of depression barely mention ECT. This is weird. I know 

—my book about ECT is also about that controversy. However, whatever you think about ECT, many psychiatrists consider it among the best treatments psychiatry has for serious affective disorder. Imagine for a moment a medical historian in another specialty writing a long history of a particular ailment, and then only briefly noting a treatment many doctors say is among the most effective! Previous histories of depression have also been a bit weak on psychoanalysis, which is a strong interest of mine.

Little existing historiography of depression focused on patient experiences and self-representations. This is not an easy area to research, because a lot of depression treatment takes place in private office practice, a confidential setting, and documentation is not really publicly available. I would have liked to do more, but I hope I pushed the field a little in that direction. I want to add immediately that some historical and other critical studies of psychiatry see patient voices as only a way to criticize psychiatry. It is important to document patient complaints, but some critics of psychiatry go to tortuous lengths to deny any therapeutic benefits. Honoring patient voices also means seeing that many feel helped by treatment.

I also wanted to draw attention to the politics of inequality. Like so many other illnesses, depression hits different populations to different extents. Solomon drew attention to this, but most of the historical work on depression restricts inquiry to the gender ratio, which is an important axis, but not the only one. Class, 

 status, for example, also matter for depression, and I hope future historians will develop this further.

Finally, I wanted to make the story more global, less focused entirely on the West, and especially the United States, although I do give the United States a lot of attention. Anthropologists and global mental health workers have looked at the wider world, but historians really have not done so for depression. I would like to have gone further here, too, and I hope others will.

: What I love about your book is that it does not settle for easy answers. It embraces the uncertainty, ambiguity, contradictions, and flux inherent in the very subject matter. One of the difficulties with studying depression is it’s a fluid entity, with variations across both time and space. Is depression the same today as it was in the 17th century when Robert Burton wrote 

? Is depression the same thing in the United States and, say, Nigeria? These are obviously thorny issues. Can you elaborate on the approach you take to address this? How can we tell a coherent history of something if we are having a hard time pinning down what that something is?

: The various illness categories—or, as it may be in some contexts, conceptions that are not illness categories—are already included in a long-running discussion of the comparability of diagnostic categories and sickness experience across time and space. The discussion is a story itself.

Most of the illness states I compare have a core feature, which is excessive sadness or blue mood, in whatever that particular context considers excessive. But some definitions of depressive illness consider this a common, but not necessary, feature for diagnosis. As you know, DSM-5 does not require depressed mood as a necessary criterion for major depressive disorder (MDD), provided there is loss of interest and 4 other symptoms. I draw (lightly) on the concept of family resemblances Ludwig Wittgenstein, PhD: Things do not need precise overlaps to have similarities that justify 

 For all the imperfections of the DSM, I think if you look at the menu of symptoms for MDD, they do form a constellation of related signs of suffering that have been clumped together in disparate contexts.

Overemphasizing cultural differences has its own risks. I show in chapter 1 the idea that African societies had little or no depression had roots in some frankly racist ideas. Universalizing labels can be a form of cultural imperialism, but overinsistence on difference forecloses possibilities for meaningful comparisons. And some who think depression is a purely modern or Western illness might be surprised at how many cultures, across time and space, have had some conception of excessive sadness as a malady.

Chiara Thuminger, PhD, is a great historian of madness with whom I am collaborating on a new project.

She has set forth 4 principles for comparisons 

1. The human mind is biological, a part of a shared evolutionary heritage, so you can expect some measure of universality.

2. The mind and mental life are not confined to the brain, but involve other parts of the body.

3. Mind and brain are situated in and shaped by culture, so universality will always be limited.

4. Every individual has an irreducible quality, uniqueness.

I think these are great principles to keep in mind.

: You are clearly dissatisfied with a lot of popular critiques of depression. You write, “One thing this book is not is a long lament on the overdiagnosis of depression, and the turning of life’s normal suffering into a medical problem.” Tell us more about your dissatisfaction with this line of criticism.

: Many people look at the high numbers of individuals with a depression diagnosis compared with previous times and take it as self-evident that we are overdiagnosing. It is not. Rising diagnosis rates is a valid reason for concern about overdiagnosis, but it is not proof. In 1950, much of psychiatry was concerned that we were underdiagnosing depression, so from that perspective, we may be finding a lot that we had been missing. We should at least consider the upside: More diagnosis means that more individuals who could use professional help are getting it.

As for medicating the normal pain of living, we should keep in mind that getting treatment for depression, whether in psychotherapy or with antidepressants, does not protect anyone from suffering, although one hopes it is reduced. Life remains hard. And many patients with depression welcome sadness as a relief from feelings of deadness or numbness inside.

In the book, I offer some defense of antidepressants against their most severe critics. But I also think we are probably overreliant on antidepressants. I think the benefits of psychotherapy, particularly long-term insight-oriented therapy, have become underrated in the antidepressant era.

Still, why some advocates of psychotherapy are so adamantly and categorically opposed to any medication use, or to any suggestion of a biological component to depression, is a mystery to me. I have read many hardline critiques of biological and pharmaceutical psychiatry that are focused on whether the evidence for efficacy is robust, or questioning the philosophical underpinnings of the enterprise, or worried about adverse effects, or indicting the pharmaceutical industry. The thoughtful challenges have reinforced my view that we are overreliant on drugs, at least for some populations. Other critiques have struck me as dogma masquerading as critique. But even the smartest of them have not convinced me that antidepressants are worthless, a claim several important voices have made.

The biology of depression is incompletely known, and much of it may remain permanently elusive. However, the idea that depression is purely psychological is, I think, implausible. Yet, so is the view that depression is purely biological. The dichotomy itself is the problem. Mark Solms, PhD, said that mind and brain are 2 ways of looking at the same thing. I find this more helpful. I do not understand how something could affect either the mind or the brain independently of the other. That is not a coherent idea.

I am getting away from your question a little, but it is an important point. Proponents of a life history emphasis in etiology sometimes take it as self-evident that if trauma or neglect is the cause, the better solution must be psychotherapeutic, as opposed to somatic. Psychotherapy might be the better treatment, but it is not self-evident just from the etiology. And the reverse: Individuals who lean toward more organic theories of etiology—genes, brain chemistry—sometimes take it as self-evident that the better solution must be something more physical, like a drug or ECT. Again, this could be true, but it is far from self-evident. In any event, I think monocausal approaches to etiology are misguided.

: You write at one point, “The growing interest in depression led more people, both professional and lay, to learn to label problems as depression, which was a growing idiom of distress before the advent of antidepressants . . . The medications, though, provided new incentives for multiple actors—pharmaceutical companies, doctors, patients, and patient’s families—to identify cases of depression.”

 I suspect you would have been writing a very different history of depression if antidepressant medications had not been developed, or if their use had continued to be severely restricted due to tolerability.

A curious thing, however, is that anxiety disorders are more common in the general community than depressive disorders, and antidepressants such as selective serotonin reuptake inhibitors (SSRIs) are not just antidepressants but also antianxiety medications. We could perhaps imagine an alternative history in which anxiety was the idiom of distress, SSRIs had been marketed as antianxiety rather than antidepressant, and you would perhaps be writing a book about the empire of anxiety, and the continuous historical links between melancholia and anxiety! Is it merely an accident of history that we ended up in the age of depression rather than the age of anxiety?

: Cross-cultural study has shown that the separation of anxiety and depression is a convention of Western psychiatry (which is rapidly becoming a global or cosmopolitan psychiatry, with both good and bad effects). Many healing systems around the world assume anxiety and depression are aspects of a single thing. And even in the West, the separation is somewhat new, a Kraepelinian innovation.

You present an interesting counterhistory. However, I am not sure the trajectory has been solely drug-driven. When the monoamine oxidase inhibitors and tricyclics were developed, psychiatrists were looking for depression treatments, and they had been doing so for decades. That is partly why these drugs came to be called antidepressants.

One curious thing is that important anxiety medications and antidepressants were introduced around the same time, and yet from a broad cultural point of view, we had first an age of anxiety—the immediate postwar period—followed by an age of depression, which started sometime in the 1970s and became more visible in the 1980s. In what I consider the most speculative portion of my book, I try to understand those periods as possibly representing wider cultural moods, perhaps rooted in different forms of capitalism. As speculative as that section is, I included it because I thought it was worth thinking about.

: You don’t spend much time discussing the creation of MDD as a diagnosis in DSM-III. I wonder how different the future course of events would have been in the absence of such a diagnostic category. If you look at DSM-II, depression was fragmented across many different sections under many different diagnoses. In DSM-II, we had diagnoses such as involutional melancholia, manic-depressive illness, depressed type, psychotic depressive reaction, depressive neurosis, and neurasthenic neurosis. I suspect that this DSM-II organization of depression would not have been particularly conducive to the process of empire-building!

: That is a great question, and I could have given this change more attention in my discussion of the DSM. However, I wonder if the creation of the category (if not the precise name) of major depressive disorder was already in process before DSM-III, reflecting the growing research interest in depressive illness in the years preceding the revision of the manual.

: When I look back at the evolution of depression, a pair of developments in recent decades appear to me to be notable, although their historical significance is probably yet to be seen. The first is the notion of treatment-resistant depression (TRD). This has led to more aggressive pharmacotherapy, such as augmenting with atypical antipsychotics, and the relatively recently approved medication esketamine.

The second is that bipolar disorder has been steadily encroaching on the territory of depression, such that even in the absence of mania or hypomania, many psychiatrists classify the presentation as being on the bipolar spectrum. Just as the development of antidepressants led to an increase in the diagnoses of depression, development of medications for bipolar depression have led to an increase in the diagnoses of bipolar disorder. Any preliminary thoughts of these developments as a historian?

: It is, of course, awful that some depressions are so hard to treat. I am not a clinician, but I wonder if many of those that seem resistant to aggressive medication treatment might respond to intensive psychotherapy, which can be expensive, or to ECT, which has risks of adverse effects (risks which are, in my opinion, generally greater than the risks of antidepressants, although I think in some cases, the risks may be worth it).

As a historian, however, I would ask if the whole category of TRD does not actually represent some progress, since it implies the other kind. A 19th-century alienist could not do much about any severe depressions at all. Many of my colleagues in history of medicine, and especially history of psychiatry, get nervous at any hint of a progress narrative, but I do not mind saying I think we have a better repertoire of treatments for depressive illness now than we did in 1850. All the treatments have downsides, but that is true of medical treatments in general.

I am aware of the rise of bipolar diagnosis, but I have not followed it closely. From a practical point of view, of course, what matters about a label is matching the individual in pain to the best treatment possible, and that is a clinical question. My historian’s take is: The safest prediction is that changes in diagnostic fashions are going to keep happening, and they will not necessarily be driven by genuine scientific advance. The whole enterprise is not worthless, but we should not assume the present trend represents the final or best word. On this point, I do worry about progress narratives.

: In a very memorable passage of your most recent book, you compare history with psychoanalysis: “[P]atients are locked into repeatedly telling the same story about themselves— about their loneliness or their victimization, for example. The therapy helps patients see that they do not have to repeat the same story. They can tell new stories of their lives. History can have a similar role . . . We do not have to live the same story, time after time.”

 Later, in the epilogue, you again refer to history as a means of guarding against compulsive repetition. Can you summarize what history tells us we can do differently going forward when it comes to depression?

: I will name 2 things. First, we do not need to keep having the same arguments about whether depression is fundamentally biological, or really the result of trauma in life, or the result of social forces. I fear that we will continue to do just that, because of the tenacity with which some individuals hold to the insistence that we must choose. It is my hope that by showing historically how insistence on a single approach leads to dead ends, we might be liberated from it. In the epilogue, I used the image of a quarreling couple, stuck in the same fights for decades on end. A good marriage counselor might be able to remind each partner that the other has things to offer.

I also hope we might be liberated from the cycle of hype and disappointment about new treatments. Most of the major treatments for depression over the last century (psychoanalysis, ECT, CBT, and antidepressants) have been overemphasized by some zealous proponents. Then disappointment (dare I say, depression?) comes when the harms or limitations of the treatments become clear. In turn, we rush to condemn the old treatment as worthless and latch on to something new, which is thought to lack the flaws of the earlier ones. But the old treatments still had something to offer, and the new ones prove to have flaws, although we may not see them right away.

New treatments are going to come, as they should. When they do, let us try not to overdo the hype, the radical rejection of the old ones, or the disappointment in the new that follows. In addition to helping patients overcome repetitions, psychotherapy can help patients to see individuals in and things in their complexity. Sometimes we, as professionals or as whole societies, can act like an individual searching for love, and finding partners we initially idealize, only to come to despise them when they inevitably disappoint us. We would do better to tolerate ambiguity. I hope Empire of Depression might help to foster that toleration.

Conversations in Critical Psychiatry is an interview series that explores critical and philosophical perspectives in psychiatry and engages with prominent commentators within and outside the profession who have made meaningful criticisms of the status quo.

The opinions expressed in the interviews are those of the participants and do not necessarily reflect the opinions of 

 is a psychiatrist in Cleveland, Ohio, and clinical assistant professor of psychiatry at Case Western Reserve University. He is a member of the executive council of Association for the Advancement of Philosophy and Psychiatry and has been actively involved in initiatives to educate psychiatrists and trainees on the intersection of philosophy and psychiatry. He is also a member of the 

is the Theodore J. Castele Professor of the History of Medicine and Associate Director of the Program in Medicine, Society, and Culture at Case Western Reserve University, Cleveland, Ohio. He holds secondary appointments in the Departments of Bioethics and Psychiatry. He earned a PhD in history from Johns Hopkins University and also studied psychiatric epidemiology at Columbia University. He has authored numerous articles and books, most recently 

Dr Aftab and Dr Sadowsky have no relevant financial disclosures or conflicts of interest.

The Noonday Demon: An Atlas of Depression

A History of the Mind and Mental Health in Classical Greek Medical Thought

Is depression the same today as it was in the 17th century? Is it the same thing in Nigeria as it is in the United States? One of the foremost historians of psychiatry weighs in. 

Exploring the Evolution of Depression

Posttraumatic stress disorder (PTSD) can be exceptionally 

. But recent studies have suggested the efficacy of a surprising option: 

For PTSD, 3,4-methyl​enedioxy​methamphetamine (MDMA) appears to be especially 

. In this Mental Health Minute, Devon Christie, MD, CCFP, IFMCP, RTC discusses her latest study results on this topic and what might be in the future for psychedelic-assisted psychotherapy.

is a family physician, a certified therapist, and medical and therapeutic services director at 

Do you have patients who might benefit from MDMA-assisted psychotherapy? 

Share comments with your colleagues by emailing 

. Comments may be shared online pending review and editing for style.

A growing body of scientific evidence suggests that mind-altering drugs, combined with psychotherapy, are effective treatments for some of the most stubborn psychiatric disorders.

What Does the Future Hold for Psychedelic-Assisted Psychotherapy?

In this Mental Health Minute, Jasmin Zapata, MD, discusses young women’s mental health and encourages clinicians to engage with the community—outside of medical settings—to promote good mental health.

books, a series offering mental health guidance to young women and girls.

How do you support young women’s mental health? 

Health outcomes are often determined by factors outside of the hospital and clinic. How can psychiatrists address mental health challenges before they become emergencies?  

Is it Time to Leave the Doctor’s Office? 

In Belgium, the Netherlands, and Luxemburg over a hundred psychiatric patients a year receive medical aid in dying (MAID). They do not need to have a terminal condition, only a degree of suffering that they find intolerable. This could include mental suffering, brought on, for instance, by depression.

MAID laws are now passing in the United States, and psychiatrists may soon face a difficult question. Should they help patients, who say their psychiatric conditions are unbearable, end their lives? In this Mental Health Minute, Mark S. Komrad, MD, discusses the various forms of MAID and makes a case against them, especially for psychiatric patients.

Read Komrad’s full feature article on MAID 

is a psychiatrist on the clinical and teaching staff of Sheppard Pratt Hospital and the Johns Hopkins Hospital in Baltimore, Maryland, clinical assistant professor of Psychiatry at the University of Maryland, and Teaching Faculty of Psychiatry at Tulane University in New Orleans.

Should psychiatrists ever assist in suicide? 

Medical aid in dying is available for psychiatric patients in European countries and Canada. Will the United States be next? 

Are Psychiatrists who Assist in Suicide Betraying Their Professional Values?

Schizophrenia and depression have long been associated with 

, an inability to experience pleasure. But recent clinical research suggests that patients with schizophrenia do in fact experience pleasure; they generally enjoy things like spending time with friends or doing well at work or in school. They just often have a hard time imagining and anticipating future enjoyment, and so they are not motivated to do the things that would make them happy.

How could psychiatrists address this motivational deficit? In this Mental Health Minute, Deanna Barch, PhD, discusses some of the emerging data from her research on 

in schizophrenia and depression. She suggests that different treatments may be necessary for these conditions, as they affect motivation and pleasure in different ways. She shares some of her early ideas about what forms these different treatments might take. 

 chair and professor of Psychology and Brain Sciences, professor of Radiology, and Gregory B Couch Professor of Psychiatry at Washington University in St. Louis.

How do you address motivational deficits in your patients? 

Being unable to experience pleasure and having difficulty imagining future enjoyment are different problems—and may require different treatments. 

New Directions in Addressing Motivational Deficits in Schizophrenia and Depression

included a Point/Counterpoint feature on electroconvulsive therapy (ECT). The feature elicited strong reactions from our readers. You can read the introductory essay, “Electroconvulsive Therapy: Obsolete and Dangerous or Still Just Misunderstood?” by Horacio A. Capote, MD, 

The authors of the original Point/Counterpoint have also continued their debate online. You can read a brief 

 for the opportunity to comment on the recent 

 articles in the April, 2021 issue on (ECT). The choice was presented as “

.” It is no choice at all: ECT is demonstrably safe and effective, but yes, still badly misunderstood.

ECT has evolved into a modern medical treatment for a limited number of psychiatric illnesses, primarily severe depression, but also psychosis and catatonia. ECT is what it is today, not what it was before modern general anesthesia, and needs to be objectively assessed, by true experts with recent experience in its use, and an understanding of the severity of the disorders it treats. We strongly support Michael E. Henry, MD’s position on ECT. He offers an accurate expert opinion based on evidence and experience. That is the information that should guide patients and physicians about ECT.

ECT has saved and improved countless lives, but as with any medical treatment or procedure, particularly one involving general anesthesia, there are risks and adverse effects; the decision to prescribe ECT always involves balancing those risks against potential benefits to the patient. That is the true, evidence-based process that expert ECT physicians follow when making a recommendation to consider ECT for a particular patient. Such a recommendation is never made cavalierly; it takes into account the severity and urgency of the psychiatric illness, the medical condition, and the treatment wishes of the patient. The informed consent process for ECT in the United States is comprehensive and follows modern ethical guidelines.

Unfortunately, misinformation perpetuates the stigma surrounding ECT. Attempts to discredit it are often based on ignorance of the realities of contemporary ECT, or worse, are ideologically driven and with questionable motives. ECT is not an ideology, a belief, or a religion. It is simply a medical procedure, with benefits and side effects. In truth there is no real point-counterpoint when one side is misinformation and distortions and the other side is medical fact.

Severe depression is disabling and sometimes life-threatening; until a worthy replacement for ECT is developed, patients and psychiatrists can be reassured that ECT is available when other treatments are ineffective. In knowledgeable medical circles, there is no controversy about that.

is the president of the International Society for ECT and Neurostimulation (ISEN). 

 is the chair of the Board of Directors of the ISEN.

A Psychiatric Times point/counterpoint feature on electroconvulsive therapy elicited strong responses.  

A Spirited Defense of ECT: From Our Readers

included a Point/Counterpoint feature on electroconvulsive therapy (ECT). You can read the introductory essay, “Electroconvulsive Therapy: Obsolete and Dangerous or Still Just Misunderstood?” by Horacio A. Capote, MD, 

 have agreed to continue their debate online. Ms. Hancock, Cunliffe, and Dr Read argue that ECT is 

. Representing the pro-ECT position, Dr Henry has responded to their article below.

I would also like to thank Sarah Hancock, MS, CRC, Sue Cunliffe, MBchB, RCPCH, John Read, PhD for responding to my article “

Their objections to electroconvulsive therapy (ECT) are primarily focused on the cognitive side effects, which they feel are caused by ECT-induced brain damage, and methodologic issues with studies supporting the efficacy of ECT. The main problem with their critique is that they appear to misinterpret the statistics they are presenting.

For example, when they discussed the findings of Peltzman and colleagues, they reported that the study found that ECT patients in the Veterans Health Administration (VHA) were 1.3 times more likely to die by suicide than 

 They failed to appreciate that when the authors compared the ECT patients to a risk-matched cohort, this finding did not meet statistical significance (

=.095), despite the large sample size of 14,810 ECT patients and 58,369 controls. They also failed to mention the authors’ conclusion that the “use of ECT in the VHA is rare. Patients who receive ECT have a complex and high-risk profile …”

 Similarly, Hancock and colleagues cite statistics from Duma and colleagues regarding 

 In their meta-analysis of the major cardiac events, the authors conservatively excluded 28 of 82 studies because they reported no adverse events. Without inclusion of this group the incidence of cardiac deaths and all-cause mortality were 0.18 and 0.33 per 1000 patients, respectively. When this group of studies was included, the incidence of cardiac deaths and all-cause mortality dropped to 0.04 and 0.13 per 1000 patients. They also did not consider that in the Veterans Health cohort, the risk ratio of all-cause mortality for the ECT group was a statistically non-significant 0.88, less than the non-ECT group.

My previous response to the question of whether ECT causes brain damage has already highlighted the findings and conclusions of Gbyl and Videbech, who reviewed 32 imaging studies of ECT with a total of 467 patients and 285 controls. They reported that none of the studies they reviewed found evidence of 

 Hancock and colleagues point to EEG, PET, SPECT, and fMRI data that show relative decreases in the activity of the frontal and temporal lobes after ECT as evidence that ECT causes brain damage.

 They do not appear to have considered the data that show depression is associated with overactivity in these same brain regions.

In addition to failing to present a balanced interpretation of the safety data for ECT, Hancock and colleagues ignore converging lines of evidence that support the efficacy of ECT. For example, they reject a study such as that published by Helle and colleagues, for lack of a 

 In this study, the authors used a randomized parallel treatment design with blinded raters to compare brief-pulse RUL to algorithm-based pharmacology in 73 subjects with bipolar depression. They found a significantly higher response rate of 73.9% for the ECT group versus 35.0% for the medication group (

 = .01). These results are remarkably similar to those of Perugi and colleagues, who treated 522 consecutive patients with treatment-resistant bipolar disorder with ECT and found response rates of 68.1 for bipolar depression, 72.9% for mixed state, 75% for mania and 80% for catatonia.

 To provide some context for these response rates, one of the pivotal clinical trials for the olanzapine/fluoxetine combination treatment for bipolar depression reported a response rate of 56.1% for the active drug versus 30.4% for the placebo treatment arm.

 Although these latter results are from a separate study, the response rates are consistent with other medication studies in this population.

Most importantly, we should not forget that the treatment options for individuals afflicted with severe depression, many of whom actively contemplate suicide frequently, are limited. Hancock and colleagues should apply balanced, rigorous scientific scrutiny to the available data before they advocate against ECT. Their analysis to date has not met that standard.

is the head of ECT and lecturer on psychiatry at Massachusetts General Hospital. He receives salary support from a National Institutes of Health grant on ECT.

1. Henry ME. ECT: an effective and safe treatment. 

2. Peltzman T, Gottlieb DJ, Shiner B, Riblet N, Watts BV. Electroconvulsive Therapy in Veterans Health Administration Hospitals: Prevalence, Patterns of Use, and Patient Characteristics. 

3. Peltzman T, Shiner B, Watts BV. Effects of Electroconvulsive Therapy on Short-Term Suicide Mortality in a Risk-Matched Patient Population. 

4. Duma A, Maleczek M, Panjikaran B, Herkner H, Karrison T, Nagele P. Major Adverse Cardiac Events and Mortality Associated with Electroconvulsive Therapy: A Systematic Review and Meta-analysis. 

5. Gbyl K, Videbech P. Electroconvulsive therapy increases brain volume in major depression: a systematic review and meta-analysis. 

6. Fosse R, Read J. Electroconvulsive treatment: hypotheses about mechanisms of action. 

7. Dale E, Pehrson AL, Jeyarajah T, et al. Effects of serotonin in the hippocampus: how SSRIs and multimodal antidepressants might regulate pyramidal cell function. 

8. Schoeyen HK, Kessler U, Andreassen OA, et al. Treatment-resistant bipolar depression: a randomized controlled trial of electroconvulsive therapy versus algorithm-based pharmacological treatment. 

9. Perugi G, Medda P, Toni C, et al. The role of electroconvulsive therapy (ECT) in bipolar disorder: effectiveness in 522 patients with bipolar depression, mixed-state, mania and catatonic features. 

10. Tohen M, Vieta E, Calabrese J, et al. Efficacy of olanzapine and olanzapine-fluoxetine combination in the treatment of bipolar I depression. 

11. Bahji A, Ermacora D, Stephenson C, et al. Comparative efficacy and tolerability of adjunctive pharmacotherapies for acute bipolar depression: a systematic review and network meta-analysis. 

12. Pompili M, Verzura C, Trovini G, et al. Lurasidone: efficacy and safety in the treatment of psychotic and mood disorders. 

Research data shows that ECT is often more effective than alternative treatments, and safe too. 

In Defense of ECT

 have agreed to continue their debate online. Below, Ms. Hancock, Ms. Cunliffe, and Dr Read argue that ECT is ineffective and unsafe. Representing the pro-ECT position, Dr Henry has responded to their article 

We thank Michael E. Henry, MD, for responding to our article electroconvulsive therapy (ECT): “

,” Henry challenges the conclusion of a recent review

 that there is no robust evidence to determine whether ECT is better than placebo: “The selection criteria used by Read and colleagues were limited to older studies (1956 to 1985).”

 The selection criteria were not time-limited. There simply have not been any placebo-controlled ECT studies since 1985.

 Furthermore the 11 pre-1986 studies were grossly flawed.

We agree with Henry that modern treatment approval requires rigorous, randomized, placebo-controlled methodology using the universally accepted standards of evidence-based medicine. ECT clearly lacks this sort of evidence-base.

Henry produces 3 traditional defences for this empirical data vacuum. First, he argues that studies without placebo control groups, such as comparing different electrode placements, are sufficient. A review of these non-placebo studies, however, revealed that none “produced robust evidence that ECT is effective for depression, primarily because at least 60% maintained ECT participants on medication, 89% produced no meaningful follow-up data beyond the end of treatment, and none investigated whether ECT prevents suicide.”

Second, Henry refers to “more than 75 years of clinical experience”

 as evidence of efficacy. Unfortunately, history is littered with treatments used for decades until deemed ineffective, harmful, or both.

Third, Henry brings up the “ethical dilemma of treating very ill patients with a placebo treatment.”

 But this assumes ECT is safe and more effective than a placebo, and that is precisely what is in question. Assuming its efficacy would position ECT proponents beyond the parameters of evidence-based medicine. Testing treatments in vulnerable populations is essential to establish efficacy, safety limits, and device regulatory protocols.

Henry portrays ECT-induced brain abnormalities, like hippocampal enlargement, as necessarily beneficial. However, a 2013 review of more than 100 imaging studies concluded “the temporarily improved scores on depression instruments following ECT reflect the combination of frontal and temporal lobe functional impairments and activation of the HPA axis and the mesocorticolimbic dopamine system. These effects as well as other detailed changes observed in structures such as the hippocampus appear consistent with those typically seen after severe stress-exposure and/or brain trauma.”

There is no evidence that ECT prevents suicide. A recent study found that 14,810 ECT patients were 1.3 times more likely to die by suicide than 58,369 ECT controls.

1. ECT provides only short-term symptom relief. There are no studies demonstrating ECT outperforms placebo beyond treatment termination, and none that it prevents suicide.

2. Between 12% and 55% of ECT recipients live with persistent memory loss,

 which is suffered disproportionately by women and older individuals, ECT’s target demographic groups.

3. Thymatron ECT device manufacturer lists 7 administration technique variables associated with risks of “

permanent brain damage and permanent memory loss

4. One in 50 ECT recipients suffer “major adverse cardiac events and death after ECT.”

5. Despite repeated requests, the US Food and Drug Administration acknowledges never receiving premarket PMA studies assessing safety or Product Development Protocols to establish 

 ECT research has still not produced any safety testing using modern clinical parameters, dosing limits, or universal administration technique protocols to reduce risks and enable replicable results.

6. Medicare reimburses ECT providers who fail to report quality data, without limits in the number of treatments provided or 

 The 34% increase in US hospitals providing ECT since device reclassification may reflect what happens when hospitals identify an unregulated income source.

7. No one knows how many Americans receive ECT each year, or how many treatments each individual receives, or 

8. ECT recipients are not provided legal informed consent regarding all risks.

9. ECT providers are not routinely assessing each patient for all known risks.

10. Repetitive intracranial mild traumatic brain injury has life-long consequence.

11. ECT recipients injured by treatment are rarely referred for comprehensive rehabilitation to improve quality of life.

12. ECT privileging requirements in the US do not include studying its 

 Without such training, psychiatrists cannot provide appropriate long-term follow-up as recommended by Thymatron device manufacturer.

Failure to acknowledge adverse effects of ECT, with life altering consequences in some patients, creates insurmountable barriers to those injured who need appropriate rehabilitation interventions to improve quality of life after treatment. ECT’s immediate and long-term damage to so many far outweigh its temporary benefits for some individuals.

 is a nationally certified rehabilitation counselor and former Clinical Rehabilitation Counseling and Clinical Mental Health faculty member at San Diego State University. More than a decade ago, Sarah received 116 ECT treatments and now lives with long-term neurological sequalae of repeated exposure to high electrical fields.

is professor of clinical psychology at the University of East London. He is chair of the International Institute for Psychiatric Drug Withdrawal and editor of the scientific journal 

. He has authored several books and more than 200 research papers.

was a pediatrician in the UK until she left her job after undergoing ECT. She has become an advocate for other ECT patients. 

. 2021;38(4):4,7. Accessed April 16, 2021.

2. Read J, Hancock S, Cunliffe S, Henry ME. ECT: dangerous on either side of the pond. 

. 2021;38(4):4-6. Accessed April 16, 2021. 

3. Read J, Kirsch I, McGrath L. Electroconvulsive therapy for depression: a review of the quality of ECT versus sham ECT trials and meta-analyses. 

4. Gregory S, Shawcross CR, Gill D. The Nottingham ECT Study. A double-blind comparison of bilateral, unilateral and simulated ECT in depressive illness. 

5. Read J, Arnold C. Is electroconvulsive therapy for depression more effective than placebo? A systematic review of studies since 2009. 

7. Peltzman T, Gottlieb DJ, Shiner B, et al. Electroconvulsive Therapy in Veterans Health Administration Hospitals: Prevalence, Patterns of Use, and Patient Characteristics. 

Regulatory Update to Thymatron System IV Instruction Manual

. Somatics, LLC; 2018. Accessed May 6, 2021. 

9. Duma A, Maleczek M, Panjikaran B, et al. Major adverse cardiac events and mortality associated with Electroconvulsive Therapy: A Systematic Review and Meta-analysis. 

10. Food and Drug Administration. Reclassification of electroconvulsive therapy devices; effective date of requirement for premarket approval for electroconvulsive therapy devices for certain specified intended uses. Published online December 26, 2018. Accessed May 6, 2021. 

11. Centers for Medicare & Medicaid Services. Medicare program: fiscal year 2021 inpatient psychiatric facilities prospective payment system and special requirements for psychiatric hospitals for fiscal year beginning October 1, 2020. 42 CFR Parts 412 and 482. 2020;16990. 

12. Hancock SP. Whose finger is taking the pulse of America’s shock treatment controversy? Mad In America. July 16, 2020. Accessed May 6, 2021. 

13. American Psychiatric Association Committee on Electroconvulsive Therapy. 

ECT has been in use for decades, but does that mean it is safe or effective? 

Depression