David John Impastato (January 8, 1903 - February 28, 1986) was an American neuropsychiatrist who pioneered the use of electroconvulsive therapy (ECT) in the United States. A treatment for mental illness initially called "electroshock," ECT was developed in 1937 by Dr. Ugo Cerletti and Lucio Bini, working in Rome.[1][2][3] Impastato has been credited with the earliest documented use of the revolutionary method in North America, administered in early 1940 to a schizophrenic female patient in New York City. Soon after, he and colleague Dr. Renato Almansi completed the first case study of ECT to appear in a U.S. publication. [4] Impastato spent the next four decades refining the technique, gaining recognition as one of its most authoritative spokesmen. He taught, lectured widely and published over fifty articles on his work. He called on ECT practitioners to observe the strictest protocols of patient safety, countered resistance to ECT from both the medical and cultural establishments, and met later challenges to electroconvulsive therapy from developments in psychopharmacology.[5][6][7] Impastato would live to see ECT recommended by the American Psychiatric Association for a distinct core of intractable mental disorders.[8][9][10] The U.S. Food and Drug Administration took longer to respond to the treatment's potential. But in 2016 the FDA drafted guidelines for ECT similar to those of the APA, as well as proposing regulations for treatment with Class II and Class III devices. [11] Though still not free of controversy, electroconvulsive therapy is the treatment of choice for an estimated 100,000 patients a year in the United States.[12][13][14][15][16]
Impastato was born in the Sicilian port town of Mazara del Vallo, the youngest in a family of ten children. In 1912, he emigrated to the United States at the age of nine, settling with his mother Rosaria and a number of his siblings in New York City's "Little Italy." His father Domenico, a schoolteacher, stayed behind in Mazara and died before he was able to join his wife and children in America. Early on it was decided that "Davide" would be the doctor in the family. His mother collected the paychecks of his older brothers and sisters, most of whom worked in New York's garment district, and redistributed the funds to family members according to need. A share of the money was set aside for young David's future education.[17] When the family moved to Brooklyn, he was enrolled at Clason Point Military Academy, run by the Lasallian Christian Brothers, to avoid the uncertainties of the local schools. He went on to receive his pre-medical degree from Columbia University in 1925, and three years later, his Doctor of Medicine from the George Washington University Medical School.[18]
During his general internship at Metropolitan Hospital Center in New York, Impastato was drawn to neurology. In 1929, he began a year of residency at New York's Central Neurological Hospital, followed by two years as clinical attending neurologist at Postgraduate Hospital (later NYU Hospital Center).[18] His presentation of spongioblastoma multiforme of the brain, published in 1932, reflects his neurological foundation.[19] That year he began a residency in Bellevue Hospital's Psychiatric Department, foreshadowing his lifelong interest in the biomedical aspects of human behavior. After his residency, he remained at Bellevue as an assistant psychiatrist, gaining the experience of the city hospital's diverse patient population of "the great, the poor, the wealthy and the unfortunate."[20] During his Bellevue tenure he was also appointed visiting neuropsychiatrist at Columbus Hospital.[18]
In 1937, certified as a Diplomate of the American Board of Psychiatry and Neurology, Impastato established his private practice in Manhattan. The same year, Drs. Ugo Cerletti and Lucio Bini, after experimentation with dogs, administered the first ECT to a catatonic patient in Rome. Though convulsive treatments for mental illness had been conducted earlier with the use of metrazol, this was the first therapeutic seizure in medical history induced by electric current.[1][2][3] Impastato was later to describe the event in The American Journal of Psychiatry.[3]
In September 1939, Dr. Renato Almansi, an Italian neuropsychiatrist and future colleague of Impastato's, emigrated to the United States to escape the rising anti-Semitism in Europe. He brought with him a version of the ECT machine that Cerletti and Bini developed for their work in Rome. Soon after arriving in New York, Almansi introduced the Cerletti-Bini device to Impastato, whose growing reputation in America had caught the attention of Dr. E. Secondari, one of Almansi's former psychiatry professors.[21][22] Impastato had seen the promise of Cerletti's revolutionary technique from the outset. After conducting his own experiments with the device over the next few months, he administered his first electroconvulsive treatment on January 7, 1940, in his West 55th Street office (see "First ECT in America" below).[21]
Almansi had been unable to persuade hospitals in Philadelphia, New York and Boston to sponsor a clinical trial of ECT. Impastato appealed to Columbus Hospital, where he had served in the Department of Neuro-Psychiatry for the prior half-dozen years.[21] Founded by Mother (now Saint) Frances Xavier Cabrini and run by the Missionary Sisters of the Sacred Heart of Jesus, Columbus Hospital might have seemed an unlikely venue for the controversial treatment. But the medical establishment's aversion to controversy weighed less with a small private hospital, and the sisters had long admired Impastato's work with mental sufferers. Rev. Mother Enrica, Mother Superior of the hospital, gave Impastato the go-ahead. He and Almansi began a clinical trial there on February 6, 1940, the earliest ECT treatments reported by any hospital in the United States.[5]
The five-month trial was conducted with male and female patients under the age of fifty. A total of 100 ECT treatments were completed "without a single complication."[4] In September of that year, Impastato and Almansi released the account of their work in the New York State Journal of Medicine, the first case study of the treatment to appear in an American publication. Almansi commented later on the changed environment. "As word spread that the treatment was being administered," he recounted, "others felt encouraged and reassured."[23] Early U.S. practitioners such as Victor Gonda, Douglas Goldman and Lothar Kalinowsky followed the landmark Impastato and Almansi article with their own published studies of ECT.[2][3][21] During the war years in the 1940s, electroconvulsive therapy would become a fixture in psychiatric centers in the U.S. and abroad.[5]
Impastato served the war effort as a psychiatric examiner, even as his practice during that period expanded rapidly into large offices on Manhattan's Fifth Avenue and a private out-patient clinic. His clientele ranged from the immigrant population to the city's elite, mirroring his Bellevue experience. He described his therapeutic approach as "eclectic," offering biomedical care as well as psychotherapy and family counselling.[24] "I am not for any one type of treatment," he explained, "I am only for the patient."[25] Emphasizing the humanity of the doctor-patient encounter, he pointed out the "psychic component in any treatment situation, even if the therapy seems to be essentially somatic."[26]
His work with ECT would continue to evolve. He authored more than fifty articles covering a range of subjects from his clinical findings, to historical notes, to his innovations in ECT technology. Impastato supplemented his published work with numerous lectures in the U.S., Europe and Asia, as well as with presentations on radio and television, becoming one of ECT's most respected voices in the international psychiatric community.[18]
Impastato was married to the former Jane Doris Justin, RN, whom he met at Bellevue and who served as his office manager and medical assistant in the first years of practice. They had three children and five grandchildren. He retained close ties with his extended Sicilian-American family, who made his achievements in medicine possible. His "genteel personality and manner," in the words of a contemporary, endeared him to those in both his personal and professional life.[27]
He was a Latinist, a geology hobbyist, a gardener, a stamp and fine-art collector, a member and benefactor of the Salmagundi Art Club of New York (the annual Jane Impastato Award), the founder of Baseball International supporting youth baseball in Italy, a volunteer consultant and forensic psychiatrist for the NYPD, and a weekly house doctor for the Metropolitan Opera. He lived with his wife and children at "Five Acres," the family residence in Pelham Manor, New York.[17]
Impastato's obituary in The New York Times incompletely cited his cause of death as pneumonia.[28] At that time he was hospitalized in Pasadena, California, in the advanced stages of Parkinsonism, which had forced his retirement after nearly fifty years of practice. He is buried at Holy Mount Cemetery, Tuckahoe, New York.[17]
Legacy
The first to administer an electroconvulsive treatment for mental illness in North America, Impastato was in the vanguard of pioneering neuroscientists who challenged the medical establishment's resistance to ECT.[6][7][29][30] He also contended with negative representations of the treatment in popular culture such as those in the novel and film One Flew Over the Cuckoo's Nest, which portrayed ECT as a punishment for unruly asylum inmates.[5][29] By the same token, he confronted his peers with the misapplications of the treatment that contributed to these stereotypes. In bracing articles published in Diseases of the Nervous System, he documented the complications that can result from ECT, including fatality, when treatment protocols are compromised. He reviewed methodologies and called for vigilance.[31][32] Improper use of ECT could be observed especially in state-hospital settings.
Impastato's concern for the patient also guided his research. Early on he experimented with sodium amytal, a barbiturate derivative that managed patients' anxiety when preparing for ECT and helped to reduce the treatment's musculoskeletal complications.[33] This line of investigation led to his breakthrough studies of the muscle-relaxant succinylcholine, which he presented in over a dozen of his articles and lectures in the early and mid 1950s. A neuromuscular blocker rather than a barbiturate depressant, succinylcholine preserves ECT's efficacy while eliminating its convulsive force in the patient. Impastato called it "the miraculous drug."[34] It has since become a procedural standard in the treatment's administration.[35]
By the 1960s, the pharmaceutical treatment of mental illness seemed poised to eclipse ECT entirely.[36] Impastato was among those who affirmed the value of drug therapy for psychiatric disorders. At the same time, he continued to advocate electroconvulsive treatment for cases that proved resistant to pharmaceutical intervention alone. "There is no conflict of interest between drug therapy and the convulsive therapies," he insisted. "Each belongs in the therapy kit of the psychiatrist."[37]
Impastato would live to see the American Psychiatric Association move beyond lingering controversy and adopt this pragmatic approach, recommending ECT in otherwise "untreatable" cases where drugs or psychotherapy remain ineffective.[8] For the APA these include depression with psychotic features, manic delirium, and catatonia when low food or fluid intake threatens the patient's life.[8][9][10] The U.S. Food and Drug Administration was slower to back the evidence of favorable ECT outcomes. But in 2016 the agency acknowledged that the benefits of electroconvulsive therapy outweighed the risks, especially to memory which in clinical trials referenced by its Draft Guidelines was shown to "return to baseline" within three moneths after treatment. The FDA responsibly proposed restricting ECT to Class II and Class III devices, the highest level of regulatory control. [11]
Both the APA and FDA guidelines confirm clinical observations dating from Impastato's earliest ECT research. "The most favorable results," he wrote with Almansi in 1940, "have been obtained in cases of recent onset, in catatonic and depressive stupor, and in the group of schizoid-depressives."[4] This seminal appraisal was published within months of Impastato's historic first treatment, which had proceeded without the sanction of his North American peers. Today in the United States, a refined ECT is the frontline therapy for an estimated 100,000 patients a year.[12][13][14][15][16]
First ECT in America
In his History of the Use of EST in the United States, Impastato describes his first treatment.[38] The procedure takes place after experimentation has been completed and while the search for a hospital venue is underway. Impastato uses the older designation "EST," since at the time the terms "electroshock" and "electrofit" were not yet superseded by the "ECT" acronym for electroconvulsive therapy:
Then in Jan 1940 I was revisited by the father of a schizophrenic patient who, seeing that his [29-year-old] daughter was becoming progressively worse, asked me if there was anything new, any new discovery that might arrest the course of her illness. As he put it, "It doesn't matter to me how dangerous the method might be, even if it should kill her, give it to her for I want her to get well if possible." His saying all this encouraged me to treat her and she became the first patient in the U.S. to receive EST. We gave her the first treatment in my office at 27 W. 55th St. ... We have her chart which I enclose showing the electric parameters we used to give her the first treatment.[39]
Zigmond Lebensohn, MD, provides specifics in his account of the event in Comprehensive Psychiatry:[40]
"Dr Impastato's records reveal the following handwritten entry for January 7, 1940: 'Volts 70, T-.1 sec MA 400. Had delayed (15sec?) reaction during apnea, face flushed, eyes opened, normal expression–looking forward, no breathing.' This treatment was administered by Dr. Impastato on a Sunday morning in his office."
Impastato's 55th Street office also served as his residence, which offered a chance opportunity for Sunday callers. His colleague, Dr. Renato Almansi, was not present during the procedure, arranged spontaneously after the unscheduled visit and the desperate plea of the patient's father. The facilities and patient's records were at hand for her examination and treatment. Impastato's wife Jane, a registered nurse, would have assisted.[17] It was certainly not unlawful for Impastato to proceed with the controversial therapy outside an official clinical setting, but it required a high degree of confidence. Medical institutions on the east coast had so far denied support for ECT research, and he ran the risk of professional censure.[36] Almansi later felt that the human urgency of the circumstances played a large part in the "precipitous" nature of the episode, among the more dramatic in the treatment's history.[40]
The treatment itself matched the initial 70 volts given by Ugo Cerletti in his first ECT three years earlier in Rome. In both Impastato's and Cerletti's patients this voltage elicited a petit mal seizure. Cerletti's patient responded by speaking coherently for the first time in years.[3] Cerletti went on to induce a grand mal seizure in the patient at a higher voltage before concluding the treatment. Impastato's single-stage petit mal procedure required only one assistant besides the operator to ensure patient safety.
Writing in the American Psychiatric Association's newsletter, Psychiatric News, Lucy Ozarin, MD, reviews the competing claims for the first ECT in the United States made by Drs. Douglas Goldman and Victor Gonda.[41] She points out that "none of these claims is supported by historical documentation." By contrast, she cites the "compelling" case made by Impastato's chart for his first ECT patient, dated January 7, 1940, which is on file with his papers in the Library and Archives of the American Psychiatric Association in Arlington, Virginia. She concludes: "In the absence of primary-source evidence to the contrary, or a differing interpolation of Impastato's file, this document would appear to identify the first ECT treatment given to a human subject in the U.S."
Electroconvulsive therapy (ECT) is a psychiatric treatment where a generalized seizure is electrically induced to manage refractory mental disorders. Typically, 70 to 120 volts are applied externally to the patient's head, resulting in approximately 800 milliamperes of direct current passing between the electrodes, for a duration of 100 milliseconds to 6 seconds, either from temple to temple or from front to back of one side of the head. However, only about 1% of the electrical current crosses the bony skull into the brain because skull impedance is about 100 times higher than skin impedance.
Ugo Cerletti was an Italian neurologist who discovered the method of electroconvulsive therapy (ECT) used in psychiatry. Electroconvulsive therapy is a therapy in which electric current is used to provoke a seizure for a short duration. This therapy is used in an attempt to treat certain mental disorders, and may be useful when other possible treatments have not, or cannot, cure the person of their mental disorder.
Manfred Joshua Sakel was an Austrian-Jewish neurophysiologist and psychiatrist, credited with developing insulin shock therapy in 1927.
Peter Roger Breggin is an American psychiatrist and critic of shock treatment and psychiatric medication and COVID-19 response. In his books, he advocates replacing psychiatry's use of drugs and electroconvulsive therapy with psychotherapy, education, empathy, love, and broader human services.
William Walters Sargant was a British psychiatrist who is remembered for the evangelical zeal with which he promoted treatments such as psychosurgery, deep sleep treatment, electroconvulsive therapy and insulin shock therapy.
Insulin shock therapy or insulin coma therapy was a form of psychiatric treatment in which patients were repeatedly injected with large doses of insulin in order to produce daily comas over several weeks. It was introduced in 1927 by Austrian-American psychiatrist Manfred Sakel and used extensively in the 1940s and 1950s, mainly for schizophrenia, before falling out of favour and being replaced by neuroleptic drugs in the 1960s.
Deep sleep therapy (DST), also called prolonged sleep treatment or continuous narcosis, is a discredited form of ostensibly psychiatric treatment in which drugs are used to keep patients unconscious for a period of days or weeks. The controversial practice led to the death of 25 patients in Chelmsford Private Hospital in New South Wales, Australia, from the early 1960s to late 1970s.
Lauretta Bender was an American child neuropsychiatrist known for developing the Bender-Gestalt Test, a psychological test designed to evaluate visual-motor maturation in children. First published by Bender in 1938, the test became widely used for assessing children's neurological function and screening for developmental disorders.
Harry Richard Bailey was an Australian psychiatrist and hospital administrator. He bore the primary responsibility for treatment of mental health patients and drug dependent clients via deep sleep therapy and other methods at a mental hospital in the Sydney North Shore suburb of Pennant Hills where he was its principal. The treatment has been linked with the deaths of a total of 85 patients, including 19 who committed suicide. Bailey committed suicide while he was being investigated. One of Bailey's clients was Australian rock and pop singer and songwriter Stevie Wright, who was being treated for methadone addiction, a report that was later part of a 2013 documentary on Australian Story.
Electroconvulsive therapy is a controversial psychiatric treatment in which seizures are induced with electricity. ECT was first used in the United Kingdom in 1939 and, although its use has been declining for several decades, it was still given to about 11,000 people a year in the early 2000s.
Harold A. Sackeim is an American psychologist and proponent of electroconvulsive therapy. He has been Chief of the Department of Biological Psychiatry at New York State Psychiatric Institute and Professor of Clinical Psychology in Psychiatry and Radiology at Columbia University. He received his bachelor's degree from Columbia in 1972; in 1974, he received his master's degree from Oxford University; and in 1977 he received his Ph.D. from the University of Pennsylvania.
Maximilian Fink is an American neurologist and psychiatrist best known for his work on ECT. His early work also included studies on the effect of psychoactive drugs on brain electrical activity; more recently he has written about the syndromes of catatonia and melancholia.
Flurothyl (Indoklon) is a volatile liquid drug from the halogenated ether family, related to inhaled anaesthetic agents such as diethyl ether, but having the opposite effects, acting as a stimulant and convulsant. A clear and stable liquid, it has a mild ethereal odor whose vapors are non-flammable. It is excreted from the body by the lungs in an unchanged state.
Linda Andre is an American psychiatric survivor activist and writer, living in New York City, who is the director of the Committee for Truth in Psychiatry (CTIP), an organization founded by Marilyn Rice in 1984 to encourage the U.S. Food and Drug Administration (FDA) to regulate electroconvulsive therapy (ECT) machines.
Leonard Roy Frank was an American human rights activist, psychiatric survivor, editor, writer, aphorist, and lecturer.
Ted Chabasinski is an American psychiatric survivor, human rights activist and attorney who lives in Berkeley, California. At the age of six, he was taken from his foster family's home and committed to a New York psychiatric facility. Diagnosed with childhood schizophrenia, he underwent intensive electroshock therapy and remained an inmate in a state psychiatric hospital until the age of seventeen. He subsequently trained as a lawyer and became active in the psychiatric survivors movement. In 1982, he was a leader in an initially successful campaign seeking to ban the use of electroshock in Berkeley, California.
Sarah H. Lisanby is an American psychiatrist who studies the use of neurostimulation devices to treat mental illness. Since 2015 she has directed the division of the National Institute of Mental Health(NIMH) working on translational research.
Psychiatry is, and has historically been, viewed as controversial by those under its care, as well as sociologists and psychiatrists themselves. There are a variety of reasons cited for this controversy, including the subjectivity of diagnosis, the use of diagnosis and treatment for social and political control including detaining citizens and treating them without consent, the side effects of treatments such as electroconvulsive therapy, antipsychotics and historical procedures like the lobotomy and other forms of psychosurgery or insulin shock therapy, and the history of racism within the profession in the United States.
Electroconvulsive therapy (ECT) is a controversial therapy used to treat certain mental illnesses such as major depressive disorder, schizophrenia, depressed bipolar disorder, manic excitement, and catatonia. These disorders are difficult to live with and often very difficult to treat, leaving individuals suffering for long periods of time. In general, ECT is not looked at as a first line approach to treating a mental disorder, but rather a last resort treatment when medications such as antidepressants are not helpful in reducing the clinical manifestations.
References
Biographical Directory of the Fellows and Members of the American Psychiatric Association. New York: Bowker, 1977. p.619. Print.
Shorter, Edward and David Healy. Shock Therapy: A History of Electroconvulsive Treatment in Mental Illness. New Brunswick, NJ: Rutgers University Press, 2007. Print.
Lebensohn, Zigmond M., MD. "The History of Electroconvulsive Therapy in the United States and Its Place in American Psychiatry: A Personal Memoir." Comprehensive Psychiatry 40:3, May/June 1999: pp.175–76. Print.
Ozarin, Lucy D., MD. "The First Use of ECT in the United States." Psychiatric News (American Psychiatric Association) August 6, 1993: Sesquicentennial Update. Print.
Impastato, David J. and Renato Almansi, MD. "Electrically Induced Convulsions in the Treatment of Mental Illness." New York State Journal of Medicine vol. 98, September 1940. Print.
Impastato, David J. "Bibliography, Lectures, Meetings, Discussions, Films, Television, Radio, Exhibits." New York, NY: The Oskar Diethelm Library, DeWitt Wallace Institute for the History of Psychiatry, Weill Cornell Medical College.
1 2 3 American Psychiatric Association. Mankad, Mehul V. et alia. Clinical Manual of Electroconvulsive Therapy. Arlington, Va: American Psychiatric Publishing, 2010. Chapter 1, "History of Electroconvulsive Therapy" by John L. Beyer, MD. Print.
1 2 3 4 5 Impastato, David J., MD. "The Story of the First Electroshock Treatment." The American Journal of Psychiatry vol. 16, June 1960: pp. 1113–1114. Print. Cf. Impastato-Cerletti correspondence, 1945–1963.
1 2 3 Impastato and Almansi, "Electrically Induced Convulsions in the Treatment of Mental Illness.," New York State Journal of Medicine vol.98, September 1940. Print.
1 2 3 4 Payne, Nancy A. and Joan Prudic. "Electroconvulsive Therapy Part I: A Perspective on the Evolution and Current Practice of ECT." Journal of Psychiatric Practice 15(5), September 2009: 346–368.
1 2 A History, Shorter and Healy, op. cit., p. 177, p. 216.
1 2 Lebensohn, Zigmond M.. "Prejudice Against ECT." Convulsive Therapy 13(4), 1997, 266–267.
1 2 3 America Psychiatric Association. Clinical Manual. op. cit., Chapter 2, "Indications for Use" by John L. Beyer, MD.
1 2 National Institute for Clinical Excellence (UK). Guidance on The Use of Electroconvulsive Therapy. London: April 2003. Section 2: "Clinical Need and Practice."
1 2 Hermann R, Dorwart R, Hoover C, Brody J (1995). "Variation in ECT use in the United States." American Journal of Psychiatry 152 (6): pp. 869–75. PMID7755116.
1 2 Smith, Daniel. "Shock and Disbelief ." Atlantic Monthly, February 2001. pp79-90.
1 2 Stone, Gene. "When Prosac Fails, Electroshock Works." New York Magazine. November 14, 1994.
1 2 Goleman, Daniel. "The Quiet Comeback of Electroshock Therapy." The New York Times, August 2, 1990, B5.
1 2 3 4 Family information courtesy of Nancy Barr Impastato." Impastato Records, Documents and Oral Histories." November, 2013. (Ancestry.com)
1 2 3 4 5 Impastato, David J. "Bibliography," op. cit. See also "General Information, Education, Appointments, Awards, Societies." New York, NY: The Osar Diethel Library, DeWitt Wallace Institute for the History of Psychiatry, Weill Cornell Medical College.
↑ Impastato, David J. "A Case of Spongioblastoma Multiforme." Medical Clinics of North America. vol. 15, 1932: pp. 1247–48. Print.
↑ Cutolo, Salvator R., MD. Bellevue Is My Home. New York: Doubleday, 1956. p. 93, quoting New York City Mayor Vincent Impellitteri's description of Bellevue Hospital at a dedication.
1 2 3 4 Impastato, David J. History of the Use of EST in the United States. 1969. New York, NY: The Osar Diethel Library, DeWitt Wallace Institute for the History of Psychiatry, Weill Cornell Medical College.
↑ Impastato, David J. Letter to Mary Anthony, February 13, 1980. American Psychiatric Association Library and Archives, Arlington, VA.
↑ Almansi on the eventual spread of ECT in the US quoted in Endler, Norman, Electroconvulsive Therapy: The Myths and The Realities. Toronto: Hans Huber, 1988. p22.
↑ Impastato, David J. "Indications and Complications of EST and Pharmacotherapy." From "A Symposium on the Importance of Shock Therapy in the Treatment of Depressive States (Montreal)." Diseases of the Nervous System, 23:11, November 1962: p. 5. Print.
↑ Impastato, David J. "Physiologic Therapy in Psychiatry." Journal of the Medical Society of New Jersey. vol. 52. October 1955: p. 528.
↑ Reiter, Joel M., MD. Personal Correspondence, December 2013. New York, NY: The Osar Diethel Library, DeWitt Wallace Institute for the History of Psychiatry, Weill Cornell Medical College.
↑ "David J. Impastato Dies; Early Backer of Electroshock." The New York Times, March 11, 1986.
1 2 Fink P.J. and A. Tasman. "The stigma of electroconvulsive therapy: A workshop." In: Fink PJ, Tasman A, editors. Stigma and Mental Illness. Arlington, Virginia: American Psychiatric Press; 1992. pp. 189–201.
↑ Kerr R.A., McGrath J.J., O'Kearney R.T., et al. "ECT: Misconceptions and Attitudes." Australia and New Zealand Journal of Psychiatry. 1982;16:43–9
↑ Impastato, David J. "Management of Acute Complications in Electroshock Therapy (The Emergency Tray)" pp. 2–5, and "Prevention of Fatalities in Electroshock Therapy" p. 7ff. Diseases of the Nervous System (Monograph Supplement). vol. 18. July 1957.
↑ Impastato, David J. "Function of the Anaesthetist in Electroshock Therapy." Diseases of the Nervous System (Monograph Supplement). vol. 19. July 1958: pp. 2–4.
↑ Impastato, David J. "The Knee Reflex As a Safety Factor in EST." The American Journal of Psychiatry 120:1, July 1963: p. 72. Print. See also David J. Impastato et al: "Succinylcholine Dichloride Modification of ES Therapy" (lecture, The Neurological Society, Philadelphia, March 1954); "The Use of Succinylcholine in EST" (lecture, Institute of Psychiatric Treatment, Boston, Sept 1954); "Methods of Administration of Succinylcholine Dichloride in Electroshock Therapy with a Description of a Simple and Modified Technic and Succinylcholine Dichloride Test" (American Journal of Psychiatry, CXII, May 1956); "A New Succinylcholine Technic" (Diseases of the Nervous System, XVIII, Jan 1957); "Practical Elimination of Fractures in Electroshock Therapy Without Barbiturates by Succinylcholine – A Control Study." (New York State Journal of Medicine, LVII, August 1957); etc.
↑ American Psychiatric Association. Clinical Manual, op cit. Chapter 6: "Anesthetics and Other Medications" by Mehul Mankad, MD and Richard D. Weiner, MD, PhD. Chapter 14: "Step-by-Step Outline of ECT Administration." Print.
1 2 A History. Shorter and Healy, op. cit, 177–212.
↑ Impastato, David J. "Effect of Drug Therapy on the Frequency of EST." American Journal of Psychotherapy 16:3, July 1962. p. 395.
↑ Impastato, David J. History of the Use of EST in the United States. op. cit. "Beginnings of EST in the New York Area."
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