A veteran reader of the first three editions of this book receives the fourth with the expectation of pain and pleasure. The pain relates to the need to drag once more through the basic science, although refreshment is ever necessary because this knowledge only fleetingly sticks. The pleasure relates to the anticipation of a masterful analysis and synthesis of a vast and important topic by a legend in the field, who will deliver an unambiguous and personal statement in a clear and often entertaining style: "Like Man, ECT is at the end of an evolutionary line, but, also like Man, rather than facing imminent extinction it is flourishing."

An interesting addition in this fourth edition is a chapter on transcranial magnetic stimulation, which Abrams sees as having potential in the treatment of depression. This was a brave prediction, for at the time of writing he had access only to reports up to and including 2000. Over the subsequent years there have been more positive reports (1). Abrams correctly points out, however, that the current method of delivering transcranial magnetic stimulation "bears as close a relationship to the methods that will be employed in 25 years hence as unmonitored sine wave bitemporal ECT bears to modern ECT."

The predicted thorough review of the basic science is present and updated. Of particular interest in the new edition is the progress in the debate over the method of determining dose: stimulus titration versus fixed dose or age-based dose. After reviewing the literature, Abrams is quite clear in his own preference: "I prefer simply setting the ECT device to deliver the maximum dose." He describes the fears of undue cognitive consequences of high-dose right unilateral ECT as "unwarranted."

An advantage of the publication is that in addition to the scholarly assessment of the literature, in chapter 9, Abrams gives a practical account of how he performs ECT. There are also reassuring practical statements, including that the higher the dose, the shorter the seizure—"confuting the frequently offered advice to increase the stimulus dose if seizures are too short, and reduce it if they are too long."

This is the most authoritative ECT monograph and has been so for almost two decades. It is essential reading for all trainee psychiatrists and essential source material for departments providing this treatment. It is based on evidence, interesting, and easy to read. Although Abrams cannot see how the treatment can be further improved, he observes that our knowledge of the mechanism of action is rudimentary, having not surpassed "in conceptual elegance the 18th-century claim that things burned because they contained phlogiston."