David J. Impastato

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. 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. 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. Impastato would live to see ECT recommended by the American Psychiatric Association for a distinct core of intractable mental disorders. 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. 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.

Life and works 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. 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.

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). 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." During his Bellevue tenure he was also appointed visiting neuropsychiatrist at Columbus Hospital. 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). 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. "I am not for any one type of treatment," he explained, "I am only for the patient." 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."

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.

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. 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. 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. 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 acting as an anti-anxiety medication when preparing patients for ECT and helped to reduce the treatment's musculoskeletal complications. This line of investigation led to his breakthrough studies of the succinylcholine, a muscle relaxant, which he presented in over a dozen of his articles and lectures in the early and mid 1950s. Unlike barbiturates that act as depressant, succinylcholine is a neuromuscular blocker, capable of eliminating its convulsive force in the patient while preserving ECT's efficacy. Impastato called it "the miraculous drug." It has since become a procedural standard in the treatment's administration.

By the 1960s, the pharmaceutical treatment of mental illness seemed poised to eclipse ECT entirely. 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."

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. 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:

Zigmond Lebensohn, MD, provides specifics in his account of the event in Comprehensive Psychiatry:

"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. 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."