Authors' reply

We are grateful for Ms Andre's interest in our paper. She is the director of the Committee for Truth in Psychiatry (CTIP), which is a vocal anti-ECT group in the USA (see http://www.harborside.com/~equinox/ect.htm). As such, we feel that our work must be on target and of some importance to attract their criticism. Ms Andre has some specific complaints with our work, which we address as follows.

First, Ms Andre suggests that I have an apparent ‘career, if not financial, conflict of interest’ that invalidates the paper, especially as pertains to my role as President of the Association of Convulsive Therapy (ACT). I receive no financial or material support for serving as president of ACT; ACT is self-supporting through the dues of its members. The idea of a ‘career conflict of interest’ is not a concept endorsed by the American Medical Association Code of Ethics, per section 8.031 (Council on Ethical and Judicial Affairs, 1997). It is just as likely that she has a conflict of interest as director of CTIP in writing her letter – any information that supports the use of ECT threatens the position of CTIP. We would welcome Ms Andre's full disclosure of her financial support from CTIP, and disclosure of the source of funding for CTIP since its website states that dues are not a requirement for membership.

Second, she claims that those in our study had an average Mini-Mental State Examination (MMSE) score of 18 at baseline. In fact, the mean baseline MMSE score was 27.4, as shown in Table 2 (McCall et al, 2004: p. 407). The minimum MMSE score for inclusion was 18.

Third, Ms Andre takes us to task for not citing Rose et al (2003). The Rose et al paper has merit, but has no direct bearing on our work. Those authors ‘aimed to... assess the debated distinction between efficacy, effectiveness, and satisfaction’; the focus of our paper is quality of life (QOL) and function, not ‘satisfaction’. As reviewed by Asadi-Lari et al (2004) satisfaction and QOL are discrete, non-overlapping ideas.

Fourth, Ms Andre asserts that memory effects of ECT must necessarily affect QOL. Ms Andre is changing the definition of terms to suit her purposes, or else remains unfamiliar with the field. QOL research is ‘... widely regarded as a robust measure of outcome assessment...’ and is defined as ‘... the patient's perspective of their own health status’ (Asadi-Lari et al, 2004). It is a violation of the concept for anyone, including Ms Andre, to define a patient's QOL for them.

Fifth, Ms Andre belittles our work for showing that ECT is associated with significant improvement in activities of daily living and instrumental activities of daily living. She does not recognise that impairment of instrumental activity of daily living may be the deciding factor in referring patients for ECT (McCall et al, 1999) and that ECT is superior to medication in improving instrumental activities of daily living over 1 year of follow-up (McCall et al, 2001).

We do share one goal with Ms Andre – a desire for truth in psychiatry. We choose to reveal truth through the scientific method as opposed to rhetoric.