So good afternoon and welcome to the Max Fink Centennial Symposium at the American Psychiatric Association. I'd like to thank the American Psychiatric Association for agreeing to host this event. And we have a panel of people who've been working with Max for many years and greatly influenced by him, including myself. So today's session will include several speakers. I'll be starting and I'll give a brief overview of Max's career, highlighting certain aspects. George Petrides, who is seated here to my left, is the associate professor of psychiatry at the Hofstra Northwell School of Medicine. He's the director of the ECT division at Zucker Institute. And he's chair of the board of directors of the ISEN. Sitting next to him is Charlie Kellner, who is the former editor of the Journal of ECT. And he's an adjunct professor at the MUSC. And sitting additionally at the end is Vaughn McCall, who is chair of psychiatry at the Medical College of Georgia and also executive vice dean. And he's the current editor of the Journal of ECT. Also presenting today, but unable to attend in person, is Greg Fritschone, who's professor of psychiatry at Harvard Medical School and director of the Benson Henry Institute at Harvard. And he'll be presenting by video. So I will start by giving a brief synopsis of Max's career. I have no disclosures, and I have no financial interest in Max Fink, although perhaps it would be beneficial to have one. So where to start with Max Fink, who, by the way, turned 100 years old. January 16, I believe, was Max's birthday. So again, happy birthday, Max. Very active. And Max is here with his family and friends on the Zoom. I have the sound off for us to hear them because of feedback. And some of us were chatting with Max earlier. So one way of thinking about Max is he thinks of psychiatry as a scientific field. Oh, and by the way, I should mention that the presentation here is adapted from a similar presentation when Max turned 90 several years ago. I think we'll be doing it again in 10 years. When the conference was in New York. And this was presented by Ned Shorter, who's a historian, medical historian at the University of Toronto, and has been a frequent collaborator with Max in recent years on articles and books. Dr. Shorter is a medical historian. And so these slides are largely adapted from his slide set with his permission. So Max views psychiatry as a scientific field and should have the same standards of scientific progress and methodology, and that's been characteristic of his career. And Max, of course, has had a special impact on many aspects of psychiatry, and we're highlighting only a few here today. So Max's contributions, just some of them. Use of the medical model in catatonia melancholia. I think hebeprenia there is a misprint, unless there's part of Max's work that I'm not aware of. The agency in convulsive therapy is the seizure, not necessarily the stimulus. And also, more laterally, fostering increased recognition of catatonia as a unique syndrome, that it's not schizophrenia. And he's done a lot, really, on nosology related to catatonia and also melancholia. So Max was born in Vienna on January 16th, 1933. And Dr. Shorter found the New York Times cover from that day, front page. And among the articles there, I took a close look at this, is the engagement of the future King George VI, being Elizabeth's father, was the announcement of his engagement that day to the lady we knew as the Queen Mother. And emigrated as a child with his family to New York, where he grew up in the Bronx. His father was a general practitioner. Here's Max graduating from high school in 1939. Max got an MD at a young age from the College of Medicine at NYU in 1945. And what Max told me was that during the war, the war years, they accelerated the curriculum because they needed doctors to handle the veterans and soldiers. For some reason, he became a ship's surgeon. And it was in context of being a ship's surgeon that he met his wife, Martha, who was a grandlady. Those of us who knew her, a gracious hostess. She was a schoolteacher, among her many other aspects. But he met Martha through his work as a ship's doctor, which he did for a short period of time. And there's Max in that smart-looking uniform. Here's Martha in her latter years with Max. We lost Martha, I think, seven years ago, after 67 years of marriage with Max. Very supportive, wonderful lady. So in the meantime, Max was quite busy. He is triple boarded. He trained in psychiatry, he trained in neurology, and he trained in psychoanalysis. And I've known Max, I met Max when I was a senior resident, PG4 resident, on job visits. And when I went to SUNY Stony Brook in New York, where Max had been, for an interview, the chairman at the time, Fritz Send, said, you've got to meet Max. And of course, that's when I first met Max. So it's, for me, going on 35 years, that I've known Max. In all that time, including when I was the inpatient director, where Max, hard to believe that I was the boss of Max as the inpatient director, and he was on the inpatient unit and also the ECT unit, I could never once get him to give a psychodynamic formulation of a case. Try like the Dickens. And I think George will confirm, heard me do that many times at case conference. So Max was triple boarded, psychiatry, neurology, and psychoanalysis. And one of his first papers is a psychodynamic paper. He had published previous papers in neurology. He was a trainee at what was then called Hillside Hospital, has had different names, Zucker Hospital, where George now is the director of the ECT division. Let me go back a second here. Whoops. Sorry. OK. So after his training, he became the director of research at Hillside Hospital, which is at the border of Queens and Long Island in New York. And while there, did amazing amount of research studies in the research division. And one of the studies was a comparative study, double blind, random controlled trial of insulin coma versus chlorpromazine. Chlorpromazine had recently been come on the market a few years ago. And this study showed that insulin coma was not superior to chlorpromazine. And it basically ended use of insulin coma. And of course, chlorpromazine was a lot safer. So this was actually a very prominent, well-known paper earlier in Max's career. Also in this period of time, Max became proficient and very interested and very proficient in EEG research. And I'll ask him about those studies in the video clip that I made with him a few weeks ago that we'll show a little bit later. And here's Max at the World Congress of Biological Psychiatry in 1957. So Max had a research team there at Hillside Hospital in New York. And among the prominent studies that he did with ECT was looking at ECT, EEG changes during ECT. And made an observation that effective treatment was associated with a change in the EEG. And also started work on what became known as Pharmaco EEG. Max has had many protégés over the years. I consider myself one of them, as do the other members of the panel. And at Hillside Hospital was Donald Klein. And a paper that they published in the early 1960s, it's amazing that this kind of study could be done. They randomly assigned patients to chlorpromazine, imipramine, or placebo to find out who got better and what were the characteristics of the people who got better. And one of the reasons they did this was that, not true anymore, of course, with the DSM, but at the time, diagnoses were lousy and very unreliable. So this was going to be a pharmacological probe to help answer the question of, for what things are these medicines helpful? And what they learned, and it became the focus of Donald Klein's future career, was that panic disorder was uniquely sensitive to imipramine. And Donald Klein went on to a long career of studying anxiety disorders and panic disorder in particular at Columbia. But it started, really, with this paper. Max got recruited to be the founding director of a research institute in St. Louis at the University of Missouri. And so they left New York in the early 60s and further developed Pharmaco EEG, which is an application of EEG to assess the effects of drugs in the human brain and also in their clinical utility. And along the way, Max was one of the first people who had a computerized EEG system. Prior to that, it was the old-fashioned way of turning pages on an EEG record. And here's Max. This would have been in the early 60s with a couple of his collaborators. On the right is Taran Atil, who was also a researcher looking at drug effects of EEG. Max came back to New York after, I think, about four years in Missouri to New York Medical College, which was primarily based at Metropolitan Hospital in New York at that time. One of his trainees was Richard Abrams. And another trainee at the time was Mickey Taylor. And those became prominent protégés who did a lot of work in ECT and also in catatonia. And you'll hear more about what their work had been a little bit later. And one of the early studies of unilateral versus bilateral convulsive therapy was published by Abrams. There was a collection of people involved in convulsive therapy practice and research in New York. And among them was Lothar Kalinowski, who is shown here. And Kalinowski was present for the first electroconvulsive treatment in Rome. But this was an era when convulsive therapy suffered greatly in the popular perspectives, primarily from movies, adverse and different influences even within psychiatry of highlighting social treatments, et cetera. So another trainee and a disciple of Max was Mickey Taylor, who is shown here. And Max and Mickey Taylor and Richard Abrams published a whole series of papers related to ECT, including a first paper on their neurochemical theories about biological effects that might underpin ECT. And Mickey Taylor and Max Fink have continued a long series of collaborations in recently writing books. The American Psychiatric Association decided to create a task force to look more closely at ECT and address questions about training, effectiveness, et cetera. And Max was a member of that panel that issued the first task force report on ECT sponsored by the American Psychiatric Association. There have been several since. And Holly, there's one coming soon, the newest edition in the next year or so? Yes. Okay. Which would be the third or? Fourth. Fourth? Yeah. So a new update of this APA sponsored guidebook of ECT is coming. But Max was a member and a very influential part of that first effort at a task force report. And in that context, to reinforce the scientific basis of what was known about ECT and also the standards of its practice and use, Max wrote the first textbook of theory and practice of ECT in the late 1970s. Max also started a journal, which you'll hear about from Drs. Kellner and McCall a little bit later, in the early 1980s. And there was an association of people interested in ECT. And there was a fostering of a relationship between that association and the journal, which I think Dr. Kellner may speak more about. And Max was the founder and also the founding editor of that journal. And this was a social event at Harold Sackheim's house in Westchester. I was present for this meeting, but somehow or other I didn't make it into the picture with all the big shots here. But Charlie Kellner did. He's right there. As well as other people from around the world who were involved in compulsive therapy and also active in that journal and organization. Throughout all of this, Max has fostered scientific interest in biology of convulsive treatment. And one of his collaborators here is a long-term collaborator, Cezanne Adelson, who's pictured here on the left. So here's Max in 2010, visiting them. So Max was asked 10 years ago, what do you think has been an impact of your efforts on convulsive therapy? And he says clinical benefits of seizures are great, anti-ECT postures are dangerous to patient care. Max is the author of a book on ethics of convulsive therapy. And that ECT is effective and safe, and it's comparable to the introduction of penicillin for neurosyphilis when applied properly. So I'll talk a little bit more about nosology. So in 1972, Max left New York Medical College and moved to Long Island at the invitation of Stanley Ellis, who was the founding chair of the Department of Psychiatry at SUNY Stony Brook, which is where I eventually started to work in 1988, some years later. And Max was an appointed professor and later a professor of neurology as well at this new medical school on Long Island. And he opened the first patient at that hospital was a psychiatric patient. And Max started the ECT service when the hospital opened in 1980 or 81. Now, Max is working on the inpatient unit, and so he's confronted with patients. And some of these are very complex tertiary care patients. So he began to become even more interested in nosology, especially for those conditions which are highly responsive to convulsive therapy, catatonia and melancholic depression. He also fostered an atmosphere of scholarly interest in psychiatry. And I would say that I'm a person who's been influenced by that. And this is just one example of Max's influence. So the Bush-Francis Catatonia Rating Scale, Dr. Bush was a resident with us at Stony Brook. And this was a resident project. And as we're about to publish it, we decided it needed a name. And Dr. Petrides was absent that day. So it became the Bush-Francis Catatonia Rating Scale, not the Bush-Petrides-Francis Catatonia Rating Scale. Sorry, George. But Max was very generous. He did not object to that. But this was just one example of Max's generativity. George and I were talking about this the other day. We had regular research meetings with the residents. Every resident had a different project. This was one project by Dr. Bush and Petrides and Dowling, who were all residents at the same time. But there were other projects related to convulsive therapy. I forgot this, George. We even did a double-blind trial of a drug for blood pressure in management of ECT. And we published that paper. And six months later, the pharmaceutical company took the drug off the market. So this was a very productive time, where Max really facilitated several residents, who later became very prominent. Another example, in addition to George Petrides, is Dirk Doshank, who was a resident and also a child psychiatry fellow, and is very active now in looking at catatonia in the autistic population and publishing on that. So Max and Mickey Taylor published a textbook of catatonia, a clinician's guide to catatonia. And Max was also very influential in persuading the DSM-5 to give us a diagnostic code for catatonia, and also to disconnect or diminish the connection previously of catatonia to schizophrenia. And both of those things were accomplished in the DSM-5. Mickey Taylor and Max have also written on melancholia. Max has written other papers on cat melancholia as well. And less successful, I think, in making a dent on the DSM approach to melancholia. Max has been active for years, fostering clinical and research interests primarily in compulsive therapy and in catatonia in recent years. And here he is appearing at an international conference 18 years ago. Here he is with Tom Bolwig and some other collaborators at a conference. I don't know if he's wearing it today, but you often see him in that turquoise sweater. So Max, this is just a few examples of Max's impact on the field and also on people who he has fostered and mentored. And I'm very happy to consider myself one of them. So Max, at 100 years old, full speed ahead. Thank you. So I think we'll switch now to Dr. Petrides. Thank you, Andy, for this review. I have to say that I'm going to focus on Max's contributions to ECT. Of course, there's going to be some overlap with Andy's presentation, but I'll try to be a little bit more specific in some things. Let me try to find how do we move. Okay. My disclosures, I have no conflicts with Max or Andy for this presentation, and I've known Max for 35 years. I did have a presentation a few days ago at the ISCN meeting, International Society of ECT and Neurostimulation. That was a little bit more personal and more emotional, I should say. I'll try to be more focused on not on personal things and memories, but what Max has contributed to ECT. This is a picture from an award ceremony when ISCN, as Andy mentioned before, honored Max at his 90th birthday. We'll start from his early years with his residency in 1952 at Hillside Hospital in New York. Actually, he went there to study psychoanalysis, but they gave him to run the insulin service and the ECT service, which was a great thing that happened to the rest of us. And that's where Max started his career as a researcher. His guiding principle was a radical principle for that time, that any treatment that causes changes in behavior must cause changes in the brain. That was not something that was self-evident at that time, believe it or not. So Max was part of the group of people who believed that and was looking for evidence for this in the brain. And one way to study it at that time was studying EEGs. So he did study several things, including EEGs, amoebarbital interviews, several other psychological interviews, including Rorschach tests. And what he showed and found, that the amoebarbital test and the EEG were sensitive in showing changes after the treatment, and those changes were associated with clinical response. So in EEG, he showed that diffused slowing, mostly theta activity, was associated with clinical response, was really significant at that point on because, again, people did not associate brain function with behavior that much when the prevailing theories at that time was psychodynamic and so. And the amoebarbital test, he would see increased confabulation and denial associated with clinical response. Actually, people who confabulate or deny their illness, they would have better outcomes after ACT. One study that helped really shape Max's conclusions or thoughts about ECT was a double-blind study of convulsive versus subconvulsive stimuli. At that time, they could do that. So people would go in the ECT room, get anesthesia, and would receive convulsive or subconvulsive stimuli. So, and they saw that there were no EEG or amoebarbital changes in the patients who had no clinical improvement, but there were changes for the patients who did, and there were no changes in the subconvulsive stimuli and changes in the convulsive stimuli. So he also did some studies with chemical induction of seizures that was fluoroethyl or endoclon that showed similar clinical response like EEG and similar, like ECT, and similar EEG changes. So those studies really were important in shaping Max's view about the need of the seizure in order to obtain clinical meaningful results from ECT. Again, Andy mentioned the really, really very important study that compared chlorpromazine versus insulin coma that led to the abandonment of insulin coma after showing that there was absolutely no advantage of insulin coma over thorazine. Max went on and for some time did not study ECT, especially in the 60s. Most of his studies were on psychotropic medications and hallucinogens that he was very much interested. He was talking to us about the LSD studies that he was doing, and he had absolutely no problem recruiting residents as subjects for that study. And again, he substantiated his effect, his EEG and pharmaco EEG attitude that EEG changes of substances are really specific according to what CNS effect a substance may have, meaning that antidepressants would have different effect than antipsychotics and so forth. After coming back from St. Louis and starting his studies at Stony Brook, as Andy mentioned, he started his collaboration with Dick Abrams and Mickey Taylor in Catatonia studies with Turani Teal. They together put, they were able to computerize the readings of EEGs, and they had a lot of pharmaco EEG studies that led to the discovery of more than 60 compounds that they had CNS effects. One of them eventually was naloxone that was established as a CNS acting drug. And he also did a lot of cannabis studies comparing different types of cannabis and their effects on the EEG. But of course, in the 1970s, the anti-psychiatry movement and hostility against ECT was very high. One flew over the cuckoo's nest. Who were there was the famous incident with Thomas Eagleton, who ran for vice president and had to step down because the media found out that he had received ECT in the 60s, and that was considered as disqualification for being vice president of the United States. But again, at the same time, there was a tremendous, so to speak, disarray within the profession with lack of formal training on ECT, no standardization, and at the same time, very poor access to ECT, especially for poor patients. ECT was available only to wealthier patients who can pay out of pocket. So the APA task force, Max was part of it, reviewed and reestablished the need for ECT, and established other things that affect us until this time, including the informed consent. Actually, as a matter of fact, initially, that task force was about to recommend very, very strict rules for informed consent that had to be videotaped, and they had to be recorded and stored somewhere. Thankfully, that was not the final report, but it is important that the consent process was established that time, and we still have it the way it is. Also, it established that ECT has to be done as a hospital-based procedure and not in offices anymore. At that time, Max wrote also the textbook that Andy mentioned, and started the ECT service at Stony Brook, founded the journal Convulsive Therapy, and he linked it to the International Association for Promotion of Electrotherapy, which later became Association of Convulsive Therapy, and later, International Society of ECT and Neurostimulation. He did put together the task force for outpatient ECT, which really set the guidelines for practicing ambulatory ECT, and he was very instrumental in the creation of the core group, which, under the leadership of Charlie Kellner, became the most productive group in ECT history, I believe, performing several multicenter studies over the years, and of course, he was very active in all the fierce debates of the 90s about electroplacement, clinical efficacy versus cognitive side effects, seizure versus stimulation, and so on. The Stony Brook projects, some of them, Andy mentioned them, I joined as a resident in 1988, mainly because Max was there. We did have a project on maintenance ECT, which was not common practice at that time. Usually, people would prescribe a number of six or 12 ECT, and that was it, and people did not consider maintenance or continuation, and that was, again, something that contributed to the formation of the core group because other groups around the country, Charlie's group and the Mayo Clinic also were doing similar projects, so that led to funding and big studies. We were treating patients with schizophrenia at Stony Brook. We reported that, and that was the basic idea that later on helped me do the studies on clozapine and ECT, and now at Hillside, there are at least four studies on schizophrenia and ECT and neuroimaging going on. We developed a half-age method for stimulus dose, and in 1998, we moved the research to Hillside, which from that point on had an unprecedented growth as an ECT service from 1,500 treatments at that time to now close to 7,000 or 8,000 treatments a year, and because Hillside is also known for its schizophrenia research, with John Kane as a leading leader at that time, we did have a lot of schizophrenia projects that are going on at Hillside. Of course, he continued his public advocacy when he retired from clinical practice, publishing books, giving interviews, and founding also our certificate course that we run at Hillside, which is a hands-on week-long course that Max was teaching up until last year when he was very annoyed with the Zoom lectures and decided that he had paid the dues but a couple of months ago, he called me, said, George, I'm bored. Can I start teaching again? So we'll do that. Charles Kellner also is a teacher in that course, and of course, he has international appreciation. People consult with him from all over the world, and he calls people who knows in services and says, oh, there is a patient in New York that might be catatonic and need ECT, would you, they called me, would you take a look, and so forth. These are some of the books related to ECT that he published, and again, we're looking forward at age 100 to see what would be the next project. Max is advocating a project with fluoroethyl, so is anyone interested, he will be very happy to discuss it with you. So Max, congratulations, I know we were listening. Happy birthday, and we're looking forward to your further contributions to the field. Thank you. Thank you, George. So Greg Fritschone was unable to attend in person, and he recorded a video. Here it is. Hello. My name is Greg Fritschone. I'm Associate Chief of Psychiatry and Director of the Benson Henry Institute at Massachusetts General Hospital. It's a privilege to be with you today. I want to thank Andy Francis for setting up this wonderful celebration for Max and for inviting me to take part. I'm going to share a screen now. Okay, we'll get started. My title is Max Stink and the Resurgence of Interest in Catatonia. I recently became a consultant to a company, Revival Therapeutics. Otherwise, I have no financial relationships to disclose. I'm going to give you a personal view of Max. I remember coming to Stony Brook 40 years ago, in 1983, after my fellowship at MGH. And I knew that Max was already a legendary professor. And he was an attending on the Inpatient Psychiatry Unit at Stony Brook. And I look forward to getting to know him. Because I knew he was one of the 20th century's greatest brain doctors. He was a phenomenally influential psychiatrist, but he was also a neurologist and a trained psychoanalyst. I also enjoyed hearing his stories about being a small plane pilot. Max was always brilliant. He was incisive, still is. Very confident. And he could be challenging. But no one was more supportive after discussion if he decided there was clear patient benefit in what was being discussed. I really came to appreciate that about him. I do remember vividly being paged by Max when there was a catatonic patient under his care on the Inpatient Unit. And I could denote a slight tone of skepticism, maybe not so slight, about the benefits of lorazepam and catatonia. Remember, he is the leading authority on ECT. And of course knew full well that ECT is the gold standard in terms of the treatment of catatonia. Yet, he wanted me to come up and give lorazepam a try. Which I did. And fortunately, I got lucky in the particular catatonics that we treated together with lorazepam. I had a quick lysis of the catatonia. And then Max was convinced. And there was no greater supporter of the use of lorazepam as a first-line treatment for catatonia than Professor Fink. I also want to mention right off the bat that we owe a great debt of gratitude to him. Because he really was the leading light in terms of rediscovery of the catatonic syndrome. Those of you who know Max know that when he gets a mission, he is going to do everything in his power to accomplish it. And he knew full well that catatonia was being insufficiently diagnosed and treated. And he was going to do something about it. And to our great benefit, he did. I should also say that another marker of his greatness is his generativity. No one more generous in trying to help people with their careers than Max. So here is an example of that. Mickey Taylor and Richard Abrams were residents with Max at Bellevue. And they have made contributions to catatonia, publishing some very important papers. Dr. Fink is quoted as saying, they were already independent faculty doing these studies. But I did teach them how to think clinically and about research. Mickey Taylor later wrote a 1990 review paper on lesions causing catatonia. And he developed criteria that to a large extent became the basis for the very important Bush-Francis Catatonia Rating Scale. They also were important in helping us understand how bipolar illness is the most likely psychogenic cause of catatonia. So, one of the major contributions Max has made in the 90s and 2000s was to reverse the great nosological error in catatonia that was promulgated by Kreplin and Bleuler. The reflexive diagnosis of schizophrenia whenever catatonia was encountered. What a mistake, right? Because of the potential damage that can be caused by our treatments for schizophrenia in terms of catatonia. Sometimes turning it into a malignant catatonia. So, in any event, Max was going to do something about it. And he worked very hard to change first DSM-IV, allowing us to move away from an exclusive diagnosis of catatonic schizophrenia to one where mood disorders and medical illnesses could be diagnosed when a patient was catatonic. He also, in DSM-V, was very strong in arguing that we should also have the opportunity to diagnose catatonia not otherwise specified. And I just review here some of the major publications spearheaded by Max to get that job done. And thank goodness that job is done largely because of Max's efforts. So, he's published over 60 articles in the past four decades on catatonia. And as I say, we can have him largely to thank for its rediscovery and the interest now. I think I've seen more articles on catatonia coming out in the last five years than ever. The other thing is that he's clearly rooted Catatonia in medicine, writ large, so it's not just a psychiatric syndrome. He published in Psychiatric in Scandinavia at that point. And then I also would point you towards this recent article by Max in the Journal of ECT on the extraordinary history of electroshock therapy in Catatonia. Another point I want to make is how having someone of Max's energy, stature, and intellect at an academic center like Stony Brook really fostered the amazing contributions that came out of Stony Brook with regard to Catatonia. So, for example, I remember conversations I had with Max about simple Catatonia, malignant Catatonia, this paper I did in 1985 in Biological Psychiatry where I pointed out the relationship of simple Catatonia with neuroleptic-induced Catatonia and of malignant Catatonia with neuroleptic malignant syndrome really got its start in discussions I had with Max. And then, of course, Max was influential with George Bush and Andy Francis and other colleagues at Stony Brook in terms of creating the Bush-Francis Catatonia rating scale and standardizing it. They have two wonderful articles in 1996 in Acta Psychiatrica Scandinavia. I particularly, of course, was appreciative with their case series showing the benefits of lorazepam. George Petrides, another Stony Brook resident and junior faculty member, became a mentee of Max's on the ECT service and he wrote an influential article on the synergy of lorazepam and ECT for Catatonia. Dirk Dosch, also a resident and junior faculty member, became a child psychiatrist and a professor down at the University of Mississippi and went on to make really seminal contributions to the relationship between autism and Catatonia and how to diagnose it and to manage it. He has a wonderful book on that topic. And then, of course, Andy, in addition to all of his other contributions in Catatonia, was one of the first to point out another nosological problem, the idea that we shouldn't make a diagnosis of Catatonia when a patient is delirious. And he pointed out, well, no, there is a subtype where Catatonia is nested in delirium. And then, in talking about Max's generativity, there's a wonderful case report. He mentored Laurie Bright-Long, a Stony Brook resident and faculty member of a 49-year-old woman who for nine years was in a nursing home diagnosed with dementia. And ECT got her out of it and returned her to a family. A great case. And then Dr. Spataki and Zervos, again, Stony Brook faculty and former residents, they did a wonderful review of our inpatient service in those years and the Catatonia cases that were seen. I remember a particular case, a sad case of a 25-year-old married mother of two who had a very, very severe case of lupus that resulted in lupus cerebritis, neuropsychiatric lupus, and a terrible case with organic psychosis that resulted in Catatonia. And she had a very complicated course with phases of withdrawal and excitement. And we tried, along with the internists and rheumatologists, courses of steroids and plasmapheresis. They failed to improve her condition. And she did not have an adequate response to lorazepam or Amitol or any epileptic drugs. And I called Max and Max treated her with ECT. And along with cyclophosphamide, she recovered and she was able to go back to her family. And we published that article in the American Journal of Medicine. And Max sent me this letter. And it was touching to realize that he was so taken with this case and this particular patient that in some ways it set him off on his quest to revolutionize our treatment of ECT. So now Max is 100 years old. And I'm still continually impressed by the contributions he continues to make. So now, after publishing a wonderful book with Ned Shorter on the madness of fear, the fact that the most predominant mood state in a patient with catatonia is fear, he's gone on to do some studies with Professor Zinghella in South Africa on the subjective experience of catatonia. These are qualitative studies. So here he is mentoring and inspiring a new generation of psychiatrists to look at this very important aspect of this terrible syndrome with such high morbidity and mortality still. So, you know, working into the 21st century, Max is still brilliant. He's still incisive, confident. He can still be challenging. But as I say, no one is more supportive when you come to him with a good argument that will benefit patients. He's a doctor's doctor through and through. Those of us who've worked with him, who've been mentored by him, really love him. He's so inspiring. He's been blessed with a really beautiful mind. And to top it off, he's still incredibly generative at 100 years young. So with that, thank you very much for listening. And I hope you enjoy the rest of the program. Thank you, Greg. Next up will be Dr. Kellner. And are you able to find it? I can't see it now. This one? And it's easy to just use these arrows up and down. Okay, great. Thank you, Andy. Good afternoon, everyone. Hello to Max and family. It really is a great pleasure and honor to be part of this panel. Thank you, Andy, for the invitation. And I'm very grateful to Max for having been a mentor, colleague, and very close friend for decades now. So I think you're going to hear a lot of similar themes to what you've heard already. But Vaughn and I are going to share the next few minutes to talk about the journal that Max founded. And I just want to tell you that before this meeting started, I went down to the exhibit hall to check Walter Kluwer, the current publisher of the journal, to make sure that it was prominently displayed. And I got there, and I didn't see a copy of the journal. And I was prepared to be quite annoyed or angry. And I went up to the gentleman who was manning the booth, and I said, Where's the journal of ECT? And he said, Oh, something happened on Saturday. There was a run on all the copies that we had. There must have been some wonderful presentation at the APA. So everybody came down here, and they wanted a copy. And we ran out of them. And it turns out that there was a presentation about pediatric ECT on Saturday, I believe, that had an overflow crowd. And I tell you that that would not have happened without the influence of Max Fink. So to the issue of the journal that we're going to talk about for the next few minutes, I don't have a disclosure slide. But if I did, I don't think I could put on it with a straight face, No Conflicts with Max, like George did, because that would not be the Max that we know and love. He's a great arguer and a strong opinion holder in the great Talmudic tradition. About two months ago, in preparing for this, I decided to ask Max to remind me of the story of the founding of the journal. And he was kind enough to write me that in an e-mail, and I just thought I would share that story in Max's own words on the next couple of slides. So he said, Alan Adelson graduated with a doctorate in chemistry from Columbia. During his studies, he helped a professor publish a document. He established Raven Press, the original publisher of the journal, and supported a number of chemistry and science journals, and he corralled a number of science editors. In 1979, he published my ECT research book, Convulsive Therapy Theory and Practice. It sold well as a follower of Hoke and Kalinowski. Martha and I met him again in Florence, Italy, 1983. He invited us to dinner, and he raised the question whether I would edit a journal for his publishing house. I suggested Pharmaco EEG, shock therapy. Would he accept shock therapy with its negative public image? If I edited it, he would accept even shock therapy. The summer went by, and we met for lunch at a Chinese restaurant in Manhattan. We talked about Florence, my book, our families. Lunch was nearly over, and he pulled a large paper from his pocket, a contract as editor with the title blank. Shock therapy? Fine, if I signed. I returned it for convulsive therapy, and Max signed the email, all the best, Max. And here I found a letter from Max's Stony Brook archives. It's a letter to a French colleague advertising the fact that Max was about to start the journal, and it says, the last paragraph, you may be pleased to know that I will edit a new journal, convulsive therapy, to be published by Raven Press, which will appear early in 1985. Should you or your associates have reports which may be suitable for such a journal, I would be pleased to receive them. And so the journal is one of Max's greatest lasting achievements. As I just said, it was founded by him in 1985, and it remains the premier site in the medical literature for clinical and scientific information about ECT. He titled it convulsive therapy and often referred and still does refer to ECT as electroshock, which I sometimes have taken issue with, but never mind. His terminology may have been from a prior generation, but his ideas were and are always occurrent and forward-looking. So the journal took hold and thrived, and after 10 successful years at the helm, Max decided it was time to relinquish the editorship to Younger Blood, and I had the privilege of taking over as editor-in-chief in 1994. I would say that I belong to the next generation of ECT practitioners, but that would be slightly inaccurate, as I am fully 30 years younger than Max. So that puts his 100 years into good perspective. My stint as editor lasted for 10 years, with Max always helping out with advice, manuscript reviews, and collegial support. So here's a picture of an early issue of convulsive therapy of the cover, and here's a picture at an early editorial board event of some kind. I think it's very symbolic because Max has his hand on my shoulder in his very supportive way. The only thing wrong with this photo is that Max looks the same today. So Max and I had a disagreement when I championed the name change of the journal to the Journal of ECT. My reasoning was that the treatment was now generally called ECT, and that the word convulsive was somewhat off-putting and stigmatizing. And so we did end up changing the name of the journal to the Journal of ECT, and Max eventually came around and was supportive of the new name, and Vaughn McCall, who's going to speak next, succeeded me as the editor in 2004. A medical journal is much less impactful if it is not fully archived and indexed in the National Library of Medicine. Max recognized this and successfully petitioned the National Library of Medicine to index the journal back to the original years of convulsive therapy. And then in the late 1990s, Max had the idea of putting together researchers in the field of ECT to conduct large-scale clinical trials, as George has mentioned. I think this must have come about with Max saying something like, Charlie, you should study maintenance ECT. And so we did. At a 1997 meeting held at Harold Sakon's lab at Columbia University, this led to the establishment of the core group, the Consortium for Research in ECT, and as George mentioned, that group ended up conducting three large clinical ECT trials over the next 20 years, and here's a paper that Max wrote summarizing many of the findings of that core group. And that effort was the core, pun intended, of the research careers of a whole next generation of ECT specialists. But Max's greatest accomplishment, as I think you've already heard, at least from George, and this is my opinion too, despite the journal and core notwithstanding, is to have kept the practice of ECT alive as a viable treatment in modern psychiatry. It's really impossible to quantify this in terms of lives saved and lives restored to health, but those numbers are undoubtedly huge, so that's a tremendous legacy. And we, his mentees and colleagues, were guided by his unflagging courage, I use that word advisedly, courage and commitment to ECT and the very ill patient population that it serves. And as you've seen earlier, no tribute to Max is complete without acknowledging Martha, his wife of many decades. She was a wonderful companion and a support to Max as well as a great friend to many of us in the ECT community. And Max and Martha often welcomed my family and I to their home in Nyssaquag, and my wife took what I think are these wonderful pictures of Max and Martha poolside. So again, thanks, Andy Francis, for putting this together. Thank you, Max, for everything, and happy belated birthday. And now I'll turn it over to Vaughan. Thank you. Hey, Max. Oh, they can't speak back to us, right. Okay. It's an honor to be part of this panel. Thank you, Andy. Many good things have come to me directly and indirectly through Max Fink. I did not have the privilege of being directly trained by him, as did this group, and so it was particularly touching to be asked to continue the journal. I'll give you one Max story that I think is emblematic of what sort of person he is. The very first time I wanted to call Max on the telephone, I had to obviously find his phone number. And this was probably almost 30 years ago. At that time he would have been 70. And I was well aware of his stature in the field. I assumed that there would be many barriers and hurdles in order to speak to him, that the first phone call would go to a departmental SHIELD administrator who would then, if I said the right things, might pass me on to his personal assistant and then eventually maybe leave a message and Max would call back some later time. So with some trepidation, I called the number I had been given, and the phone is answered and it says, Max Fink here. And it was just like that I was in. And that has always been my experience with Dr. Fink, that he is accessible, ready to help, ready to answer questions, and ready to give very sage advice. And there are a lot of lessons in that. One is that there's no point in wasting time and getting right to it. So I'm going to do that now. When I was asked to shepherd the journal in 2004, I was excited. But one of my first questions was, how long can this last? Because at the time, ECT was already 70 years old. And I thought, haven't all the important questions been answered? Was there really anything anymore to say? And I was aware that Dr. Fink was hopeful that basic science of the mechanism of ECT might lead to some fundamental brain discoveries, a discovery of a secret sauce, which would be derived from knowledge regarding ECT, but then might even permit ECT to no longer be required. That is, we would learn something, and then ECT could be put aside in favor of something else. And that has not happened. We're still at it. And the next question would be, would ECT scholars, those that submitted papers and the editorial board, have the fuel to continue to push the journal forward? And now we're at about 40, is it how many years? Almost 40 years into this process. And so I will briefly show you the signs of health behind the journal of ECT. One of Max's many offspring and what I think it holds for the future. So it's worthwhile just looking briefly at the mission statement from the journal in 1985. This comes from the first issue. And I've highlighted a few things and put a few things in red font that just stood out to me. And one was that Max saw, and I think you would say he still sees, ECT scholarship and the journal of ECT as an international enterprise, something that the world itself should own. It is not an American thing. Also of interest, and this has, I think, changed slightly, we'll look at the next mission statement in a little while, is that there was obvious inclusion of animal research, that the journal would not just be a home for human research, but also for mechanistic animal research. And then, of course, other sort of interesting flavorings, such as sociological, legal, and ethical aspects, which make what we do, I think, more interesting. But above all, you can see the last tagline is that all of this, whether it's from the U.S., outside the U.S., whether it's animal research, whether it's sociological, legal, or ethical, it should really have one principal purpose, and that is the contribution to clinical practice. As our colleagues on the panel have said, this is patient-centered. How will the patients be helped? I decided in the spirit of this idea that maybe ECT could be replaced one day if we could find the secret sauce. We've heard earlier about Max's hopes to find something. This is one of his papers contributed to Issue 3 of 1989 where he postulated a neurohumor antidepressant, something still yet to be discovered, something that is released or promoted by ECT. If I remember correctly, he conceptualizes this as a neuropeptide, and that if this could be found and engaged, then we would understand better what, in fact, we were doing and maybe lead to some sort of substitution for ECT, and we are still looking for antidepressant. We have not yet found it. Today's mission remains still very relevant. I'm not going to read all this to you again. There's still some themes here. I don't see the word animal in here, and I don't know if that's by design or by default, but I think if you read the journal, you would have to agree that while occasionally animal research appears and is helpful, is that mostly it's a clinical journal, and I think it's intended to have clinicians principally as the audience. It's intended to help the practice of ECT, although obviously basic science would be received lovingly. Another sign of health of the journal is, is anybody bothering to submit anything to it, and is it being cited? And the answer is yes. There's been a significant rise in the impact factor, which is an indicator that people are reading it, citing it, and this is very heartening, and the five-year impact factor also increasing. And then regarding the international aspects of ECT, I think all of us, myself included, would love to see this be maybe a less U.S.-centric publication. Here you see the sources of manuscripts that come to the journal, and the countries from where these accepted papers come from as well. I don't believe that it's representative that the U.S. writes the most papers, and it is the job of the journal really to bring the best research from around the world to the journal. And closing up, I just wanted to recognize the editorial board, which I think here does reflect the international flavor of the journal, and we're fortunate to have dedicated reviewers and associate editors and editorial members from around the world. So to finish up, we've heard a lot about Max's legacy, for psychiatry in general, but especially ECT, and when you think about legacies, things that live on, you know, there's certainly the body of work itself, and that's always going to stand on its own feet, very important contributions. And then there are the people that have been mentored and trained and influenced by Max, and then there's the journal, and my perspective is the journal shows signs of life and is going to continue on into the foreseeable, if not indefinite future, but it's not just the product in the journal. If you think about it, the ISCN meets once a year. Now it's back to in-person gathering once per year, and that's terrific, but how about the other 364 days per year? And my sense is that the Journal of ECT has become the gathering place for ECT scholarship. Both those that submit and those that review and serve on the editorial board, and this is, I think, one of Max's great legacy contributions, is a scholarly community which has been created through the Journal of ECT, and Max, we thank you greatly for that. Thank you, Vaughn. So what I'd like to do now is, although Max and his family are attending on the Zoom, I did make a video with Max a couple of weeks ago, because I don't trust technology, and so this was, I want to... Thank you for agreeing to be interviewed. So I wanted to let people who haven't met Max or heard him present get a flavor of kind of who he is, and as mentioned, Max is a man with strong opinions, and I've always felt that talking to Max sharpens you up, sharpens up your thinking, and you'll see he's a person with some strong opinions. So this is from about, well, it's in March. So we're meeting today with Max. It's March 29th. Sorry. I was trying to make it louder. Thank you for agreeing to be interviewed, Dr. Fink. So we're meeting today with Max. It's March 29th, and Max is in his home in Massachusetts, looking very comfortable. So good afternoon, Max. Good afternoon. So we're making this video in conjunction with the Max Fink Centennial Symposium, which is upcoming in May, in San Francisco at the APA. So I wanted to just let people meet you in person and be very impressed. By the way, congratulations again on your 100th birthday. Yes. And how you remain active and engaged, and it's so impressive. So we're going to be highlighting certain aspects of your career in this symposium, but I wanted to discuss some other things with you about your life. You gave us a summary of your 10 most favorite, so to speak, publications, and on that list, most of them were not the things you're most well-known for in the field today. Most of them were not on EC, convulsive therapy, or atatonia. They were mostly on EEG, psychopharm, and pharmaco EEG, and the DST. So I want to talk a little bit about some of these aspects of your career, where you spent good chunks of your life working. So could you kind of enlighten us, what was pharmaco EEG? What is the basic premise of that? This was a big part of your career. When we administered these drugs to patients and measured the EEG before, during, and after, we were able to show different patterns. There were four major patterns that Teal worked on. There were some eight patterns that I worked on that we had different EEG patterns as a result of the drug effect. And that became a very strong point to show that drugs were different. The problem was that when the new drugs came in from the pharmaceutical industry in the 1970s and 80s, they did not have definite EEG effects. They were one of the more drastic things was I had a new compound from Organon that Taran and I paralleled. I had already moved. He was in St. Louis. And we showed that this compound did not have an EEG effect. When we told that to the company, they sort of smiled at us and said, but in the animals, it works. That's very important. Well, these drugs then became all the drugs that we now have are animal sensitive but not human sensitive. Well, I recall a paper you wrote. So a paper was published about clozapine producing changes in the EEG. And the authors of that paper viewed this as a terrible problem. But I recall you wrote a response to this saying, well, this is actually good news because it means the drug is working and doing something in the brain. I think that's true, yes. I interpreted when systematic changes in the EEG occurred, I interpreted those as being either positive or negative in the sense that what was changed was the brain function. And that made it possible for the drug to have an effect. Unfortunately, the drugs we now have do not have a defined EEG effect. And pharmaco EEG has essentially disappeared. I'd like to shift topics a little bit, Max, and talk a little bit about the historical atmosphere of what it must have been like 70 plus years ago in the early 1950s as a, quote, biological, unquote, psychiatrist in practicing in hospitals where the dominant mentality was psychodynamic. So as I understand it, patients would come to a hospital and receive assessments and attempts at psychological treatments. And if these failed, they would be, quote, referred, unquote, for biological treatments. Is this correct? It depends on which hospital you're talking about. Well, I'm glad you work in such a place. Well, the issue was that most of the patients who were admitted to Hillside and then to Missouri or to New York Medical were patients who were quite sick. They were admitted for a severe illness. And the idea of treating them with medications became the standard treatment. So what do you think, what do you see in the future in psychiatry? What trends do you see becoming dominant? Like, for example, emerging field of neuromodulation, all sorts of physical stimuli, of which ECT is the granddaddy, so to speak. Physical stimuli of one kind or another, ultrasound, magnetic, electrical. One of the facts that I learned in studying the EEG of drugs and the EEG of ECT was that the EEG changes dramatically and measurably in the patients who are treated effectively. What happens is, if you get a patient who does not have an EEG change, they do not have a behavioral response. So the issue of TMS and other stimulation techniques is that they are designed specifically not to produce an EEG change. They are designed to produce a change if any at all is transient. And therefore, on the basis of the experience with ECT, then I don't think any of these are effective. And as most people now know that neurostimulation and neuromodulation are techniques for social care of patients. You're not ending very positive on the prediction of the future of those things. Well, presumably, it's treating a different, it's offering a treatment to a different segment of the clinical population of, quote, depression, unquote, or mood disorder. Well, that's being optimistic. At the moment, from the reports, reports are, published reports of neuromodulation and neurostimulation and these other things, they don't have much effect on the patient's brain. Well, I guess time will tell. Where this hallucinogenic drug effort goes in our field, but it's an interesting aspect of psychiatry that's growing, both in research and clinical. I would agree that the hallucinogenic science and their application is an attempt to treat human beings in a way that is different from previous treatments. And I think that's a worthwhile experiment. If you would have a population of patients, if you could find some depressed patients who are melancholic depressed, or some catatonic patients, or some psychotic patients, like postpartum, et cetera, you can maybe find a treatment effect that is faster and more effective than the usual thing that we use today. Yeah. Well, there is certainly a lot of research effort ongoing in academic centers for hallucinogenic drugs. I think we'll stop the recording there. Thank you very much. It's very exciting to answer your questions. Thanks so much for agreeing to do this, Max. And we do appreciate it. And again, happy birthday. Applause So when I show this to the residents at my program, it's not their picture of a 100-year-old man speaking. I thought before we opened things to discussion that maybe those of us on the panel might give a personal reminiscence, just some example from our own lives and career that Max made an impact. So if you guys want to think for a minute, I'll start with one on my own. So Max stayed at Stony Brook for 26 years, from 1972 to 1998, and so did I. I was there from 1988 to 2014. And when I left, I got recruited to Penn State Medical School to be the director of the ECT program. And the chairman at the time, Alan Gellenberg, said, well, I feel I know you, but I need some kind of a reference letter. So I said, well, Alan, would a letter from Max think that I can run an ECT service suffice? Would that be enough? He said, okay, I think that'll be enough. It would be good enough. Anyone on the panel want to give a sort of personal anecdote? Well, I have a lot of them, but as I mentioned to the talk that I gave earlier at the IASCN, I don't think there's anyone who has been more influenced in their careers than I have been, just because I crossed a continent and an ocean to be here and be trained with Max. And it was really by, I think, or what I thought at that time, because the greatest chance that it took was that I did interview in many places that gave me interviews for a residency. And some of them, they gave me positions out of the match, and I had to sign. I was really pressured to do it quickly. But Stony Brook didn't. I had to stay on the match. So at the end, I decided to stay on the match, and I was really so happy that I matched. And Max was the reason. And when I first started my residency, I did my first rotations at the VA in medicine, and then my co-residents, we were doing their rotations with Max, they started worrying me. He's very strict. You have to be on time. You have to be on time. You have to be 7.30. You have to be there. And I was living, like, 50 miles away. So I knew that. So I was really horrified that I have to be on time. And he was, I mean, he never expressed any dissatisfaction with that. His first dissatisfaction was that I had devised this plan that since I have to be there at 7.30, I had to leave home at the latest at 6.30. I had to have breakfast. I have to wake up, like, 5.30, but I didn't have time to shave. So I would shave the night before. So Max, at some point, asked me, if you don't believe in shaving, I did have a shave by the morning. So, well, that shows that there was some conflicts. Well, I'm just going to comment on what gracious hosts Max and Martha always were. In the 1980s, I was interested in ECT, and, of course, I knew of Max, and he didn't know me from Adam, and I called him up, like Vaughn was saying, and I thought I would stay at a hotel somewhere on Long Island when I came to visit them. But no, he invited me. They invited me to their house, and they were just such wonderful hosts. And the other thing I will say is that my children, who are all grown now, have the most wonderful fond memories of visiting the Finks in the summer on Nyssaquag, and they always ask about Max and Martha. This one's a little difficult to talk about because it's sort of embarrassing, but, you know, I think every time someone gives you a diploma and says you've now graduated college, you've now graduated medical school, you're now a resident, there's a bit of a sense of the imposter syndrome. You've heard this before. You're not quite sure you are as good as people think you might be. Early on in an ISEN meeting, it wasn't called ISEN, it was an ACT. It was an ACT meeting, which would have been probably the early 90s or so. This was at least 30 years ago. I walked up to Max, and he was with somebody else, and he knew who I was, which by itself was astounding. And he's pointing to me, he said, this is the future of ECT. Now, I'm sure he told this to all the boys, right? I was probably not the only one. But I've got to tell you, what a boost, you know, to feel like maybe it's going to be OK and you're going to have a career in academia, and the message from that is just his willingness to be supportive in a very direct way, unequivocal, that, you know, you're going to be OK, you're going to make a contribution. And there's a lesson there, I think, now that some of us are old men to, you know, do the good turn to the younger people. That was very kind of him. I'd like to give Max the last word. This is a one-minute clip. And this is from 2018. I would say that I was a very active and loving... So Max donated his arc, when he left Long Island, Max donated his archive to the library at SUNY Stony Brook. And this was a video made in conjunction with the time that he donated his archive. ...clinician scientist. That is, I became interested in neuropsychiatry. That is, what is neurology and psychiatry today. And I made some contributions. I think I was very lucky. However I worked it out, I was always able to find projects and kept busy and have written books. We've saved lives, knowingly. It's been a very interesting life. So I think we'll have to officially close the program at 5.15. And those of you who'd like to share any information, I think we on the panel will be here at least for a few minutes. So thank you all for coming. And again, Max, happy birthday and thanks for your contributions. And hello to your family and friends as well.

Max Fink

Centennial Symposium

American Psychiatric Association

electroconvulsive therapy

ECT

psychiatry

insulin coma

chlorpromazine

pharmaco EEG

catatonia

melancholia

DSM-V

Journal of ECT