Letters to the editor

By
Shock and Disbelief

"Shock and Disbelief," by Daniel Smith (February Atlantic), incorrectly characterizes those who urge caution on electroconvulsive therapy as falling into one of three groups: "a handful of former ECT patients, some dissenting psychiatrists, and the Church of Scientology." Smith may be surprised to learn that a number of established organizations in the mental-health field also believe that a high degree of caution is warranted. For example, the official policy statement of the National Mental Health Association, America's oldest and largest nonprofit organization addressing all aspects of mental health and mental illness, includes the recommendation "that ECT be presented as an alternative with extreme caution, only after all other treatment approaches, such as medication and psychotherapy, have either failed or have been seriously and thoroughly evaluated and rejected."

Although many people have been helped by ECT, it is a mistake to discount the compelling stories of those who have suffered severe and permanent disability in its wake. Although they may represent a minority of recipients, there is no way to know in advance who will experience similar deficits, as even proponents admit. As a result, ECT should remain a treatment of last resort, and the choice to use it must be a truly informed decision, made competently and without coercion.

Michael M. Faenza
National Mental Health Association
Alexandria, Va.

In 1960, when I was seventeen, electroshock therapy literally saved my life. After three months in a private psychiatric institution I was sent home, where, in spite of changes in medication and increased doctor visits, I simply could not cope, and found temporary relief by way of an overdose that rendered me unconscious but near death.

Back at the institution, my doctor started me on higher doses of medication in hopes of breaking the grip of this suicidal depression, but sustainable relief came only after my doctor administered ten electroshock treatments over the course of three weeks. I was no longer agitated or anxious. The depression that almost took my life finally became manageable after more than a year of struggle. Eventually it would dissipate, leaving me to finish my schooling, marry, raise two children, and enjoy a successful career.

Did I suffer a loss of memory? Of course. A little or a lot? Doesn't matter. Was it a fair tradeoff? Unquestionably. If needed, would I undergo such therapy again, or encourage others to? Without hesitation.

Cathy McCulloch
New Milford, Conn.

I read "Shock and Disbelief" with great hope, thinking that surely Daniel Smith would have unearthed some scientific evidence that ECT benefits patients. There were the usual anecdotes and testimonials, as can be found for any therapy throughout the history of medicine. But not a word about randomized studies or other means of determining the actual efficacy of ECT as compared with no treatment or with any other form of treatment for depression. Is ECT just a high-voltage placebo effect?

Thomas A. Preston, M.D.
Professor of Medicine
University of Washington
Seattle, Wash.

The one and only mission of the Committee for Truth in Psychiatry is to advocate truthful informed consent to ECT. We take no position on any other issue, including whether or not ECT should be banned. We do not make the claims that are attributed to us in "Shock and Disbelief." Our work does not include the activities Smith describes, such as instigating lawsuits.

The article portrays us as a bunch of crazies who oppose ECT for no reason other than that we are irrational anti-ECT, anti-psychiatry fanatics. To do this, Smith has to omit the most-important material facts: that all of our members had ECT, that we all have permanent memory loss, and that none of us were told of this possibility when we gave our consent. He also had to omit any mention of the actual work we do—for instance, we were instrumental in getting the Food and Drug Administration, which regulates ECT machines, to acknowledge that ECT's adverse effects include brain damage and memory loss, and we have worked to keep the ECT device in the FDA's highest-risk category, Class III, where it stands today.

Smith also had to invert the truth to make his speculations about my current mental health. I am not mentally ill. I haven't had a symptom or a diagnosis, seen a shrink, or taken a single psych pill in more than sixteen years. Nor have I ever in my life been committed or "recommitted" to a mental hospital.

When Smith writes, "Andre, Sackeim says, has shown him her medical records; he says that she may have experienced a similar breakdown" (to that which left a nameless mental patient allegedly unable to hold a job at a fast-food restaurant), he leads the reader to the conclusions that I showed Harold Sackeim my medical records and that these records, apparently psychiatric records, show that I am disabled by mental illness. Both conclusions are false.

The truth is this: the only personal record I ever showed Sackeim, many years after shock, was the neuropsychological report attributing my brain damage to ECT. Smith knew what this report said—he reports its finding that my IQ dropped dramatically after ECT. He simply left out its further finding that the loss was due to ECT. Smith suggests, inferentially, that I am one of only a very few ECT survivors who have suffered loss of intelligence and devastating permanent amnesia. Hundreds of such cases are documented in the FDA files and medical journals.

On what basis does Smith assure his readers that electroshock is "safe"? He cites no evidence, not a single safety study. Has he reviewed the research of the past sixty years, and is he qualified to discredit the human and animal evidence for brain damage? Has he conducted his own studies? Has he reviewed all forty volumes of the FDA files, as I have? His quoted experts Max Fink, Sackeim, and Charles Kellner have never done safety studies. As for effectiveness, Smith either doesn't know or chose not to mention that even the industry concedes that ECT has no benefit that lasts for more than four weeks.

Linda Andre
New York, N.Y.

Daniel Smith replies:

Linda Andre correctly notes that the Committee for Truth in Psychiatry is devoted to advocating for informed consent. Nothing in the section of my article concerning CTIP states that CTIP's mission is to abolish electroconvulsive therapy or that the organization files lawsuits. At the outset of the article I observed that a number of activist groups, taken collectively, were engaged in a whole range of activities (making a public case against ECT, agitating politically for curbs on ECT, instituting lawsuits), and Andre may have taken this to mean that every group is engaged in all the activities. CTIP's declared mission is to lobby for improved informed consent, a commitment that arises out of its belief that ECT "'works' by damaging the brain" and that this information is withheld from patients by psychiatrists. That all members of CTIP have experienced ECT is clearly stated in the article.

The article neither states nor implies that Andre is now mentally ill. As for the chronology of Andre's past hospitalizations, the paragraph was read to her word for word; she made one small correction, which was incorporated in the printed text. In my interview with her Andre reported that she was given ECT at New York Hospital's Payne Whitney Psychiatric Clinic in 1984, and that she had been "locked up" and "treated against [her] will."

As for Harold Sackeim, I reported what he told me—that Andre had shown him her medical records. I did not specify which records he had seen, nor did I imply that Andre's loss of IQ, which she herself told me about, was a result of mental illness. I have not seen the neuropsychology report that Andre refers to, and therefore cannot comment on its findings.

I did not suggest that Andre is one of a very few ECT patients who have experienced a profound loss of memory. In fact, I stated in my article that memory loss is a significant issue, and I observed critically that psychiatrists long played down the possibility of such a side effect. I also noted that the report published this year by the APA Committee on ECT contains that organization's first substantial discussion of the possibility of serious memory problems. However, patients reporting this level of cognitive impairment represent only a small percentage of patients who receive ECT.

In characterizing ECT as "safe," I was reporting the views of many psychiatric experts, and also the views of many ECT patients—that ECT does not injure the brain. As in the treatment I described, ECT is now administered as safely as any other medical procedure. Bodily injury, which once was common, is now extremely rare.

Are the benefits of ECT limited? I state that it is not a cure but a useful treatment, with limitations, for severe mental illness. ECT is used on many occasions to pull patients out of a severe illness when other treatments have failed, or when quick relief is needed to save a patient's life; since relapse is indeed common, often medication or "maintenance" ECT is necessary thereafter.

Interested readers can find more commentary by Linda Andre in the Science section of Post & Riposte, on The Atlantic's Web site.

Casablanca

This note will surely be lost in a fog of corrective correspondence about Casablanca's "unforgettable" closing airport scene, but here goes: Peter Berkowitz ("Wooed by Freedom?," October Atlantic) is wrong to say that Keith Angus (Letters, February Atlantic) was right to say that Rick does not shoot Major Strasser. Rick does. Berkowitz is right to say that Angus is wrong to say that the French police captain Louis's ensuing command to "round up the usual suspects" is cynical. But Berkowitz is only half right to say that Louis's order represents the triumph of "friendship over cynicism." It also—at least as important—represents the triumph of moral integrity over convenience. Louis, finally, does the right thing. But if he had shot Strasser, as both Angus and Berkowitz remember it, his famous command would have been merely self-serving, and we wouldn't have had much of a picture to not forget.

Kelly Garrett
Santa Cruz, Calif.

I am shocked, shocked! that both Peter Berkowitz and Keith C. Angus are wrong about who shot Major Strasser at the end of Casablanca. I refer them to scene 278A of the screenplay (page 156 of the original typewritten version), which I quote in its entirety:

"RICK: Put it down.

"Strasser, his one hand with the receiver, pulls out a pistol with the other hand and shoots quickly at Rick. The bullet misses its mark. Rick now shoots at Strasser, who crumples to the ground."

Louis Wynne
Albuquerque, N. Mex.

Peter Berkowitz replies:

The mind plays tricks even with the unforgettable. I am grateful to Kelly Garrett and Louis Wynne for setting the record straight about who shot Major Strasser, which has the additional happy consequence of strengthening the original point in my essay: in Bogart's Rick love and nobility are united in a way that seems quite out of fashion yet continues to touch our hearts.

Indoctrinologists

The most important aspect of Sally Satel's "The Indoctrinologists Are Coming" (January Atlantic) is its slighting of scientific studies documenting disparities in the treatment of African-American and Hispanic patients, which suggest physician bias and stereotyping, however unconscious.

An example: Satel's consideration of coronary-artery and other heart disease. Two recent searches of the relevant medical literature have identified and examined 170 articles on racial and ethnic disparities in treatment in this category alone. All but a handful described inferior treatment for minority patients, ranging from failure to provide clinically needed bypass surgery to the omission of clot-busting and other recommended drugs—even aspirin—for African-American as compared with white heart-attack victims. These are studies of real patients with real diseases in real hospitals, not the make-believe patients in the one study Satel appears to have read. They compare black and white patients matched for insurance coverage, severity and stage of disease, presence or absence of other disease, income, education, age, and other important variables.

Satel asserts that medical and public-health leaders display a "stubborn reluctance to acknowledge that each person has some responsibility for preserving his or her own health." Has she not noticed the enormous efforts being made in health education and preventive medicine relating to diet, tobacco and other drug use, and regular exercise? Is she unaware of the studies showing that these personal behaviors, important as they are, account for only about a third of the differences in health status of different population groups—leaving the other two thirds to be found among the very social, racial, and economic factors that she wants us to quit studying?

The National Academy of Sciences' Institute of Medicine—arguably the most distinguished group of clinicians, basic-science researchers, public-health officials, and other experts in the nation—has concluded that "public health is what we as a society do collectively to assure the conditions in which people can be healthy." That is not political correctness; it is medical and social correctness.

H. Jack Geiger, M.D.
Arthur C. Logan Professor of Community Medicine, Emeritus
CUNY Medical School
New York, N.Y.

Sally Satel replies:

H. Jack Geiger is utterly wrong in saying that I want researchers to quit studying social correlates of health. I only urge that the work be scientifically rigorous and the interpretations uncontaminated with political activism.

I also hope that the public will be skeptical in the face of the media's tendency to trumpet weak evidence as proof of gross racial prejudice. That is exactly what happened with the Schulman study and why I wrote about it. Though it was a well-designed, experimental observational study of doctors' treatment patterns, an erroneous interpretation of its findings—namely, that blacks were 40 percent less likely to be referred for cardiac catheterization—made headlines claiming discrimination in medicine.

I cannot comment on all 170 studies Geiger cites, but let's just take one he mentions about bypass surgery and aspirin. That study appeared in the journal Circulation last August. It showed a two percent difference in aspirin-prescribing—a small difference. It also showed a seven percent black-white difference in receipt of invasive procedures. But a close reading of the study suggests two possible explanations for the latter. First, black patients may have had less supplemental health insurance. Second, the black patient group most likely contained a disproportionate number of females, and female patients of any race are less likely than males to undergo invasive cardiac procedures. Clearly, I differ with Dr. Geiger's thinking that the discrepancies are obvious examples of bias, especially when other variables are yet to be explained. In other instances it is reasonable to consider bias as a hypothesis, but that is what it is: a hypothesis.

I vigorously applaud the efforts of the public-health profession to encourage people to adopt a healthy lifestyle. Indeed, those very efforts have extended and improved millions of lives. The indoctrinologists, in contrast, are often dismissive of personal responsibility, sometimes even contemptuous of it. Consider, for example, the comments of Stephen Bezruchka, of the University of Washington School of Public Health. In so mainstream a venue as Newsweek (February 26, 2001) he says, "Research during this last decade has shown that the health of a group of people is not affected substantially by individual behaviors such as smoking, diet and exercise ... our primary goal should be to reduce today's record gap between rich and poor." A worthy goal for politicians, yes—not for health professionals, who must keep their eyes on practical interventions.

French Protestants

In the article "Province of the Past," by Peter Davison (January Atlantic), the author is way off the mark in writing that Protestants from southern France were exiled to "Quebec or New Orleans." Under the Bourbon monarchy Protestants were forbidden from migrating to French colonies. That's why French-Canadians, whose ancestors crossed the Atlantic from 1608 to 1759, are traditionally all Catholics, and why there's such a large percentage of Catholics in southern Louisiana (virtually all the people of French or Spanish descent). French "Huguenots" (Protestants) were more likely to go to the Netherlands, Prussia, South Carolina, or Capetown. As for the Occitan spoken in southern France, it never was used in the American Colonies, where 90 percent of the French came from the northwestern part of France, mainly Normandy, Brittanny, and Poitou.

André Pelchat
Victoriaville, Quebec

Peter Davison replies:

As happens far too often, an American writer has proved his ignorance of Canadian history. I apologize for my error and thank André Pelchat for correcting it.

Correction:

The January Letters to the Editor included one from Stanley A. Plotkin, of Doylestown, Pennsylvania, regarding Jon Cohen's article "The Hunt for the Origin of AIDS" (October Atlantic). The name of Dr. Plotkin's co-signer, Bette Korber, of the Los Alamos National Laboratory and the Santa Fe Institute, was inadvertently omitted. We regret the error.

This article available online at:

http://www.theatlantic.com/magazine/archive/2001/05/letters-to-the-editor/302208/