"Classics in ECT": Max Fink Responds to a Lancet Editorial
"Classics in ECT" brings you this LTE from The Lancet, in 1979:Efficacy of ECT
Lancet. 1979 Dec 15;2(8155):1303-4. doi: 10.1016/s0140-6736(79)92317-1.PMID: 93218
The pdf is here.
And from the text of the letter:
Sir,
The peremptory question in your Oct. 27 editorial
stimulates a different reply from the one you give. ECT has
not been "until lately ... almost completely neglected by
research workers". Evidence of its efficacy, changes in procedures to ensure greater safety, and many studies of the mechanism of action fill more than 1200 references in a recent review.
…Some studies have examined the efficacy of seizure and
non-seizure therapies. These have been criticised on methodological grounds, but I would criticise them as redundant andmissing the mark. The principal scientific issue today for ECT
research is the mode of action, not the efficacy or the safety of
convulsive therapy in depression and catatonia.
In this letter (a response to the editorial in The Lancet, "ECT, 40 years on"), Dr. Fink summarizes the history of ECT, advancements in treatment technique and safety and has a table, "Efficacy of ECT in Psychotic Depression," showing studies of ECT versus sham, placebo, TCA and MAOIs.
This is a powerful defense of ECT research, and a call for more, that continues to resonate and feel totally modern.
Importantly, it was published in The Lancet, with arguably the largest general medical audience in the world; it is the responsibility of leaders in the field to keep ECT front and center in the medical literature, continuing to press for its acceptance as a mainstream treatment.
The below comment is from Max Fink:
ReplyDeleteFink Lancet : Status of ECT research September 23, 2020
We are 40 years beyond these arguments, and the state of ECT research is, sadly, still preoccupied by electricity and without an understanding of the unique mechanism of inducing seizures to alter human behavior. This blog is filled with notes on electrode placement, follow-up studies, cognition, brain imaging and genetics, and scalp titillations by TMS and tDCS. In 1979 I was able to defend the state of clinical care as effective and safe for the relief of psychotic depression, mania, and catatonia. Alas, that is all that we know today, having wasted four decades following the pipers of memory loss, brain damage, minimal seizure threshold dosing, that dominate studies and treatments, even today.
My associates and I published three random treatment trials of RUL and BT treatments in1958, 19731, and 20072. The third was sponsored by NIMH, a comparison of two multi-site university collaborations known as CORE and CUC. All aspects of the admissions, diagnoses, assessments, and cognition were the same, except that CUC patients received RUL treatments, while CORE patients received BT placements. RUL placement treatments were less than 60% effective, BT placements greater than 85% effective. RUL treatments required an average of 10 seizures compared to 7 for BT, a saving in a week's illness, risks, and costs. And, neither study group could document persistent cognitive defects.
A seizure is a physiological patterned behavior that is a universal atavism in mammals. It is akin to a cough or sneeze, a defense mechanism. Each seizure is patterned by nature; nothing in electricity is essential to the seizure. The years of fiddling with currents is akin to choosing to turn a light switch by the finger, the elbow, the nose -- the outcome is always the same. The electricity is both efficient and inefficient -- that is why I have suggested that we could do away with electricity by using the inhalant flurothyl.3
Once we do away with electricity, we can attend to the main issues-- the full grand mal seizure and its EEG record as a record of the brain events. We can study the neuroendocrine effects that dominate the outcomes in melancholia4,5 and catatonia6,7.
After 80+ years, it is time to discard attention to the electricity and the MDD, TRD, and BPD labels that muck up diagnoses, and pay attention to mechanisms that are best tested in catatonia and melancholia, that have verification tests and identify homogeneous populations for research studies.
Inducing seizures to relieve catatonia and melancholia is an unheralded story in medicine, unheralded in 1979 and unheralded in 2020.
Max Fink
1 Fink M. Convulsive Therapy: Theory and Practice. NY: Raven Press, 1979
2 Fink M, Taylor MA. Electroconvulsive therapy: Evidence and challenges. JAMA 2007; 298: 330-332.
3 Cooper K, Fink M. The chemical induction of seizures in psychiatric therapy: Were flurothyl (Indoklon) and pentylenetetrazol (Metrazol) abandoned prematurely? J Clinical Psychopharmacology. 2014; 34(5):602-7.
4Taylor MA, Fink M. Melancholia: The Diagnosis, Pathophysiology, and Treatment of Depressive Disorders. Cambridge UK: Cambridge University Press, 2006.
5 Shorter E, Fink M. Endocrine Psychiatry: Solving the Riddle of Melancholia. Oxford University Press, 2010.
6 Fink M, Taylor MA. Catatonia. A Clinician’s Guide to Diagnosis and Treatment. Cambridge UK: Cambridge University Press, 2003.
7 Shorter E, Fink M. The Madness of Fear: A History of Catatonia. NY: Oxford University Press, 2018