Through the Times With Max Fink, M.D.

Psychiatric Times

September 2005

Vol. XXII

Issue 10

For much of his career, Max Fink, M.D., has been viewed as a pre-eminent researcher and advocate for electroconvulsive therapy. But older physicians, he said, identify him with electroencephalography, psychopharmacology and research on substance abuse.

Fink's parents met at medical school in Vienna, Austria, where he was born in 1923. They emigrated to New York in 1924. Fink received his M.D. degree from the New York University College of Medicine in 1945 and interned for nine months before becoming a medical officer in the U.S. Army. "I was in the Army for about a year when they sent me to the School of Military Neuropsychiatry at Fort Sam Houston, Texas," he told Psychiatric Times. He spent four months there and when finished, "I was a qualified psychiatrist and neurologist, according to the Army."

Following his Army discharge, Fink took his residency training at Montefiore Medical Center, Bellevue Psychiatric Hospital, Hillside Hospital (now a division of Long Island Jewish Medical Center) and Mt. Sinai Hospital. He became board certified in neurology in 1952 and in psychiatry two years later. He also received a certificate in psychoanalysis from the William Alanson White Institute of Psychiatry in 1953. With credentials in hand, he opened a private practice in neurology and psychiatry in 1953 in Great Neck, N.Y., and kept it open until 1958 when he became a "full-time academic."

Early on, Fink was intrigued with electroencephalography. The National Foundation for Infantile Paralysis gave him a fellowship in 1953 that enabled him to work at Mt. Sinai Hospital learning EEG. He developed a methodology for computer analysis of EEGs, wrote many papers on the effects of psychotropic drugs on the EEG and organized conferences on that subject.

From 1959 to 1985, he conducted extensive research into quantitative pharmaco-EEG (QEEG). The first studies were done at Hillside Hospital, then from 1962 to 1966 at Washington University in St. Louis, where he was research professor in psychiatry. The studies continued, with extensive support from the National Institute of Mental Health, when he joined the faculties at New York Medical College and then the State University of New York (SUNY) at Stony Brook.

Fink's interest in pharmacology coincided with the arrival of major psychotropic medications in the mid-1950s. He conducted a random assignment study of chlorpromazine (Thorazine), for example, in patients referred for insulin coma. Published in JAMA in 1958, that study showed chlorpromazine to be as effective as and safer than insulin coma, and it strongly influenced the end of the active use of insulin coma (Fink et al., 1958). In 1960, Fink became a member of NIMH's Clinical Committee that established the Early Clinical Drug Evaluation Units (ECDEU) under the leadership of Jonathan O. Cole, M.D., now senior consultant in psychopharmacology at McLean Hospital and professor of psychiatry at Harvard Medical School.

Fink's move into substance abuse research came in 1966 when he became professor of psychiatry at New York Medical College.

"Alfred Freedman, M.D., who would later become president of the American Psychiatric Association, needed someone who was interested in opiates, and he invited me to join his faculty. I knew nothing about marijuana or opiates, but I came back to New York and opened up a research program in narcotics," Fink said. "We did a lot of work with naloxone [Narcan] and with opioids themselves. We studied heroin, narcotic antagonists and methadone [Dolophine, Methadose] in patients."

The federal government gave Fink a research contract to compare hashish use in Greek participants to cannabis use in New York participants.

"I went to Athens, organized a research team, and we studied the effects of hashish on neuropsychology, cardiac physiology, electroencephalography and psychosis," he said. The outcome of that research was several papers and two books: Chronic Cannabis Use (Dornbush et al., 1976) and Hashish: Studies of Long-Term Use (Stefanis et al., 1977).

Expertise in ECT

Beyond his ventures into QEEG, psychopharmacology and substance abuse research, Fink has maintained a consistent interest in ECT.

During his residency at Hillside Hospital, Fink said he "learned something about electroshock and insulin coma." In 1954, the hospital asked him to direct a newly created department of experimental psychiatry. He published widely on predictors of outcome in ECT, effects of seizures on EEG and speech, hypotheses of the mode of action, and how to achieve effective treatment.

In 1972, NIMH asked Fink, Seymour Kety, M.D., of Harvard and James McGaugh, Ph.D., of the University of California at Irvine, to organize a conference on the mechanism of action of ECT. That conference resulted in Psychobiology of Convulsive Therapy (Fink et al., 1974).

"Partly because of that book, in 1975 the American Psychiatric Association asked me to be a member of the Task Force on ECT," he said, adding that in 1979 he wrote a textbook on ECT, Convulsive Therapy: Theory and Practice [Fink, 1979]. "Then, in 1984 I gave a plenary lecture in Florence, Italy, on electroshock. A publisher, Alan Edelson of Raven Press, who was sitting in the audience, invited me to dinner and asked if I would like to edit a journal for him. I said sure, and in 1985, we started a quarterly journal of convulsive therapy, now named the Journal of ECT, which is in its 21st year of publication."

A member of Psychiatric Times' board of directors since 2002, Fink has also been a regular columnist for the publication for many years, usually writing about ECT. In 1995, he was presented with PT's Lifetime Achievement Award. He has received numerous other awards, including the Anna Monika Prize in 1979, the Society of Biological Psychiatry's Gold Medal in 1988, and the Hungarian National Institute for Nervous and Mental Disease's Laszlo Meduna Prize in 1986, named after the physician credited with using convulsive therapy for the first time in 1934.

Asked why ECT substantially decreased in use from 1960 to 1980, Fink replied: "There was a popular belief that the psychotropic drugs would replace ECT," he told PT. "There were three treatments being used before the drugs: electroshock, insulin coma and lobotomy. The lobotomy was never tested against a psychotropic drug; it was just dropped because people didn't like the treatment. Electroshock was dropped because people believed the drugs would do as well. By the middle 1960s, we knew that ECT was more effective than pills, but nobody wanted to do ECT, because ECT is like a surgical procedure. You have to lay hands on a patient, and it takes 20 to 30 minutes for each treatment as against eight or nine minutes to write a prescription. And the pills do quite well."

But sometime in the mid-1980s, Fink said, "psychiatrists became aware that they had a large number of chronic mentally ill patients in their practices. They talked about therapy-resistant psychosis, therapy-resistant schizophrenia and therapy-resistant depression ... We would then ask, how can we say someone is therapy-resistant if we haven't given that person all the treatments that doctors know? At that point, it became obvious that there are people, particularly people who are psychotically depressed, who do better with ECT than pills. So, somewhere between the early 1980s and early 1990s, ECT had a revival. The [APA] brought together a second APA Task Force that reviewed the evidence and published the APA's Task Force Report of 1990 [The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging] in which they said quite clearly that ECT works for certain kinds of patients (American Psychiatric Association Committee on Electroconvulsive Therapy, 2001)."

Even with the development of newer medications, such as the selective serotonin reuptake inhibitors, the serotonin norepinephrine reuptake inhibitors and atypical antipsychotics, Fink said, there are many patients who do not get well and become chronically ill. "Many articles describe therapy-resistant depression, and this, of course, is the main reason why ECT has come back," he said.

"There is no official count, but in 1996 the estimate was that 100,000 patients per year were being treated with ECT in the United States [Ottosson and Fink, 2004] ... If you take the 100,000 estimate per year and each patient gets an average of 10 treatments, that's about 1 million treatments in 1996," he said. Fink believes that now the numbers being treated in the United States are beyond 100,000 patients per year, and he sees a revival of ECT in Europe as well.

"In 1991, I was invited to go on a lecture tour in Holland. I gave seven lectures in five days at different universities and hospitals, and they were all about ECT. At that time, ECT use in Holland was the lowest in Europe. It was almost impossible to get the treatment," he said. "In January of this year, I went to a meeting in Brussels [Belgium]. A Dutch speaker described a significant use of ECT in Holland. In fact, they got so interested that the Dutch have published numerous research articles and a handbook of ECT. The same has happened in Germany and Austria, where usage has increased and a new German text has been published."

Electroconvulsive therapy is an effective treatment for severe mental disorders, including psychotic depression, delirious mania, catatonia, postpartum depression and postpartum psychosis, Fink said.

He has defined delirious mania as a syndrome of the acute onset of the excitement, grandiosity, emotional lability, delusions and insomnia characteristic of mania, and the disorientation and altered consciousness characteristic of delirium (Fink, 1999).

"Psychotic depression is a life-threatening disease," Fink said. "It has a very high mortality rate. Psychotic depression does not respond to pills easily. Yet, almost every patient with psychotic depression treated with ECT does well.

"Also, a form of mania, called delirious mania or manic excitement, is quickly fatal unless treated adequately. Patients are usually 'snowed-under' with antipsychotics, and a number develop the neuroleptic malignant syndrome. It is better to treat such patients with ECT," he said.

Catatonia does not respond to the usual drugs, Fink said. Benzodiazepines are effective in 70% to 80% of the cases. When they don't work, ECT usually does, he added.

For postpartum depression and postpartum psychosis, Fink said, "ECT is a remarkable treatment."

Age, No Barrier

Age is no barrier, according to Fink, who has explained that ECT has been used successfully in children, adolescents and the old-old (Fink, 2001).

Today, Fink told PT, "It is reasonable for child psychiatrists who are not wedded to psychodynamic thinking to consider ECT in children and adolescents with the illnesses for which ECT is used in adults."

In a column for PT ("Reconsidering ECT in Adolescents" January 1995, p18), he cited the evidence for the efficacy of ECT for some adolescents and children suffering from mental illnesses, particularly those with major depressive syndromes, delirious mania, catatonia and acute delusional psychoses.

In recent years, child psychiatrists are taking more of an interest in ECT, Fink said. The American Academy of Child and Adolescent Psychiatry has published a practice parameter for the use of ECT with adolescents (Ghaziuddin et al., 2004). The authors concluded it may be an effective treatment for adolescents with severe mood disorders and other Axis I psychiatric disorders when more conservative treatments have been unsuccessful.

Continuation ECT

With regards to Fink's more recent research, in 1997 he was a principal investigator in a multicenter collaborative study group known as CORE under grants from NIMH. The overall aim of the study is to compare continuation ECT with pharmacotherapy in the prevention of relapse after a successful course of ECT.

"I have been active in that program up until this year. We finished the last patient in the first study, and we have since gotten two other NIMH grants to study other aspects of ECT," he said.

Data collection has been completed for the first study, and a report has been submitted for publication, Fink said. Earlier this year, suicide data from the first phase of the study was published (Kellner et al., 2005). It looked at the incidence, severity and course of expressed suicidal intent in depressed patients who were treated with ECT. The authors concluded, "Expressed suicidal intent in depressed patients was rapidly relieved with ECT," raising the issue of whether ECT should be considered earlier than its "last resort" position in evidence-based treatment algorithms for major depressive mood disorders.

Asked what he wants psychiatrists and others to understand about ECT, Fink responded, "Over the 70-plus years that ECT has been around, we have learned to appreciate that something magical happens in the body when we produce an epileptic fit."

Yet, neurologists and internists reflect the public fear of an epileptic attack. A major part of neurological practice is devoted to suppressing seizures, and this attitude influences the approach of neuroscientists to seizures, Fink said.

"What we have learned about ECT is that nothing about the electricity, nothing about the chemicals used in anesthesia, nothing about a psychological aspect in the process is important, except producing a grand mal seizure in the brain," he said.

Citing an example, he explained that anesthesia during ECT makes the process easier for the patient and the physician, but it is not essential to the outcome. "The only thing that is essential is the seizure ... Therefore, if you are going to treat patients, you have to know how to produce a seizure well," he said.

Yet, it is almost impossible to get neuroscientists to look at ECT as a science, according to Fink. Rather, they look upon it as a bizarre piece of ancient history. There is very little study of the mechanism of ECT. Scientists need to investigate the effects of seizures on human beings and why seizures can help in the treatment of mental disorders.

"I have written a number of papers on what is called the neuroendocrine hypothesis of the mode of action of induced seizures [Fink, 2002]; other people have other ideas, but there is just no question that the seizure is the essential part," he said.

In 1997, Fink retired and became professor emeritus at SUNY at Stony Brook, but he has kept busy as lecturer, consultant on legal cases, and author, spending a good part of his day writing. He has more time to spend with his family--his wife Martha of 56 years, their three children and four grandchildren. Two daughters are professors of biology and the son, a professor of geology.

Fink wrote Electroshock: Restoring the Mind in 1999, and then partnered with a former student, Michael Taylor, M.D., adjunct clinical professor at the University of Michigan, to write Catatonia: A Clinician's Guide to Diagnosis and Treatment in 2003. He went on to co-author Ethics of ECT with Jan-Otto Ottosson of the University of Goteborg, Sweden (Ottosson and Fink, 2004). His latest project is a book on melancholia with co-author Taylor.

"We have just finished Melancholia: The Diagnosis, Pathophysiology and Treatment of Depressive Illness. It took us three years and is more than 800 pages in typescript. It challenges the DSM-IV division of mood disorders into major depression and bipolar disorders, offering a simplified classification, much like the simplified classification of catatonia offered in an earlier book. It has been sent to Cambridge University Press," he said. "We plan to have it out in March 2006, in time for a major international meeting on melancholia to be held in Copenhagen in May."

References

American Psychiatric Association Committee on Electroconvulsive Therapy (2001), The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging. Washington, D.C.: American Psychiatric Association.

Dornbush RL, Freedman AM, Fink M, eds. (1976), Chronic Cannabis Use. New York: New York Academy of Sciences.

Fink M (1979), Convulsive Therapy: Theory and Practice. New York: Raven Press.

Fink M (1999), Delirious mania. Bipolar Disord 1(1):54-60.

Fink M (2001), ECT has much to offer our patients: it should not be ignored. World J Biol Psychiatry 2(1):1-8.

Fink M (2002), Catatonia and ECT: Meduna's biological antagonism hypothesis reconsidered. World J Biol Psychiatry 3(2):105-108.

Fink M, Kety S, McGaugh J, Williams T, eds. (1974), Psychobiology of Convulsive Therapy. Washington, D.C.: V.H. Winston.

Fink M, Shaw R, Gross GE, Coleman FS (1958), Comparative study of chlorpromazine and insulin coma in therapy of psychosis. J Am Med Assoc 166(15):1846-1850.

Fink M, Taylor MA (2003), Catatonia: A Clinician's Guide to Diagnosis and Treatment. New York: Cambridge University Press.

Ghaziuddin N, Kutcher SP, Knapp P et al. (2004), Practice parameter for use of electroconvulsive therapy with adolescents. J Am Acad Child Adolesc Psychiatry 43(12):1521-1539.

Kellner CH, Fink M, Knapp R et al. (2005), Relief of expressed suicidal intent by ECT: a consortium for research in ECT study. Am J Psychiatry 162(5):977-982.

Ottosson J-O, Fink M (2004), An Ethical Dilemma: Ethics in Electroconvulsive Therapy. New York: Brunner-Routledge.

Stefanis C, Dornbush RL, Fink M, eds. (1977), Hashish: Studies of Long-Term Use. New York: Raven Press.