Ordinarily Wrong: A Misdiagnosis Crank-Started the Full-Bore Iatrogenic Hell of Psychopharmacology

Before Antidepressants, you know, He Wasted Away in a Mental Institution. That’s the name for a gripping anecdote, as re-told for the readership of the Daily Beast by Tara Wanda Merrigan. It’s no doubt music to the ears of those who don’t know what to think about antidepressant drugs and psychiatrists (1). That’s an especially tough position for the intelligentsia, who have two aspirations that inform their beliefs and actions: to be up on science news, especially news that Trump supporters decry, and to stick it to the big man, he of Big Oil, Big Banking, and Big Pharma, without hurting their chances of employment at establishment employers with iron-clad benefits and easily-toutable programs in support of diversity and inclusiveness (diverticulosis if they can only have one). They know the Bigs get wealth and power through misdeeds, but to side with the anti-psychopharmacology crowd invites accusations of illogic and conspiracy-theorism. Thank heaven the Daily Beast has settled the question in favor of pharmaceuticals…for now.

Let’s learn about the man whose luck is said to have been changed by antidepressants from a few sources and wind up with Ms. Merrick’s portrayal. He was a nephrologist whose case was a milestone in the field of law and psychiatry, written up with almost the same details in many publications, including:

in Responsibilities and Dispensations: Behavior, Science, & American Justice,

In 1979, Raphael Joseph (“Ray”) Osheroff, M.D., was a 41-year-old, hard-driven kidney specialist with a $300,000-a-year practice and an expensive home in the historic Washington suburb of Alexandria, VA. It was only then that Ray’s recurrent mild depression began to spiral out of control. He lost 40 pounds, stopped bathing and shaving, and his uncut hair soon hung limply to his shoulders. He began to pace uncontrollably, every waking moment of the day, until the soles of his feet blistered, ulcerated, and turned black. When his thoughts began to turn to suicide, Dr. Osheroff asked his medical partner and closest friend to take him to the most prestigious private psychiatric hospital in the Washington area;  Chestnut Lodge in suburban Maryland (2). 

in Psychiatry in Law / Law in Psychiatry, Second Edition,

…[his feet] blistered, ulcerated, and turned black. He lost 40 pounds and stopped bathing and shaving. He could not sit still long enough to eat with a knife and fork; instead, he would snatch food off a plastic tray as he paced. He repeatedly asked for medication, but “forget drugs,” his hospital psychiatrist told him, they would only obscure his real problem—a narcissistic personality disorder rooted in his relationship with his mother (3).

in The Washington Post,

No matter how badly he wanted to, Ray Osheroff couldn’t stop pacing. For months he had spent nearly every waking moment — sometimes 16 hours — trudging an estimated 18 miles a day up and down the hall of a locked ward in a mental hospital. The soles of his feet blistered, ulcerated and turned black. He lost 40 pounds and stopped bathing and shaving. His uncut hair hung in limp hanks on his shoulders. He couldn’t sit still long enough to eat with a knife and fork — instead, he would snatch food off a plastic tray as he paced. Osheroff, a doctor, repeatedly asked for medication to control the crushing despair that propelled him up and down the hall. Forget drugs, his hospital psychiatrist told him, they would only obscure his real problem — a narcissistic personality disorder rooted in his relationship with his mother (4).

and as Merrigan relayed it for The Daily Beast,

During his seven months at the Chestnut Lodge mental hospital, Dr. Ray Osheroff lost 40 pounds. He spent 16 hours a day pacing up and down the hall of his locked ward. His despair was so great he couldn’t even sit still to eat, instead snatching food off a plastic tray as he walked (5).

Terrible, terrible. But a little more information comes in and a membrane stretches and rips apart, leaving ragged edges and a loaded silence. 

Pop.

Pop.

Dr. Osheroff had been treated with tricyclic antidepressants before he got to the Lodge.

He wasn’t pacing under his own steam. Along with his supposed narcissism, he exhibited the symptoms of akathisia, something that many readers have known since the first mention of pacing. Akathisia wouldn’t have arisen on its own. It’s a type of injury caused by psychotropic drugs, especially “atypical” (or second generation) antipsychotic drugs, typical antipsychotic drugs, and antidepressants of all types.  You can allege “agitated depression” or “psychotic depression,” but does that occur, with this symptom, in the absence of psychotropic drugs? I haven’t heard of it, but I stand ready to be educated. Osheroff had taken just the right drugs to cause intense akathisia, although Merrigan and the others failed to mention them. The correct title for Merrigan’s piece can be usefully amended to: “After Antidepressants, He Wasted Away in a Mental Institution.”

Yes, Dr. Osheroff had been on and off a tricyclic antidepressant before he ever go to Chestnut Lodge.

I can’t say enough about the hellishness of akathisia. Sufferers can have entirely healthy minds without hang-ups, worries, stresses, or losses to grieve, but having taken a drug that induces akathisia, they will invariably say things like “I pray to God to kill me every day,” and “I can’t take another minute it of this.” They are not suicidal; that is a special and rare state of mind. By the same token, they can barely tolerate consciousness. They cannot stand still. They cannot sit down. To lie down and take a nap is impossible. Lying down lasts seconds, not minutes, until the compulsion to arise kicks in. Back they go to the pacing, running up and down staircases, or running in place. Remaining still isn’t an option.

For good measure the mind is stuck on rumination of past mistakes, losses and victimizations. There is no accommodating anything akin to hope, optimism, or an even keel. It’s a black doom encased in an empty skull without a crack to let the light in. The look of akathisia is shattered pot metal. The sound is high-pitched tinnitus. The scent is gases emanating from a superfund site.

Dr. Osheroff’s case is significant because he recovered and resumed his career and sued the pants off everyone in sight. Before that, his mother and father had suctioned him out of Chestnut Lodge and deposited him in a new facility. He was better within weeks. The common and incomplete explanation is that all it took was an antidepressant. Less common, but correct, is that he was given an antidepressant and an antipsychotic. The Chestnut Lodge crew’s explanation was that his mother’s attention and a romantic relationship at the new place made the difference. It cannot be denied that attention from the opposite sex is the fastest road to a shave and a haircut, but it is more likely that one (or possibly both) of the drugs he was prescribed eliminated the akathisia. (I haven’t been able to find out which drugs were used.) That does not make drugs the hero of this story, though. It reinforces their role as villain.

As someone who endured misdiagnosed akathisia for many weeks after being prescribed a selective norepinephrine and serotonin re-uptake inhibitor for an ailment I didn’t have, and an atypical antipsychotic to combat its side effects, which were misdiagnosed as a new ailment, I don’t believe the dynamics of his relations with females ended his akathisia, or that a change of surroundings would have mattered any more than it would in Stage 4 cancer, which I’ve also enjoyed. In akathisia, there are no other people or surroundings in the usual sense. They can be seen and heard but all that is experienced is desperate desperation concentrated on the case for dying, soon, now, because dying presents itself as the one sure thing, and there is no time to monkey around. Being struck dead is guaranteed to answer the sufferer’s plea for anything, anything at all, to not feel like this. There’s no relent. It’s all day, all week, all month and for some all year, and while it’s blazing, one cannot take care of oneself. Dr. Osheroff was lucky that a tray of food was proffered along his route so that with every lap he had a chance to put something in his mouth that would sustain him until the next time he rounded that particular bend.

Prozac-listener Dr. Peter D. Kramer’s explanation was that Dr. Osheroff’s ailment was psychotic depression, relieved by the antipsychotic (5). He surmises that treatment with an antidepressant alone would have been the end of Dr. Osheroff. Not so fast, pal. The antidepressant might have acted as hair of the dog, and in that case, the antipsychotic might have done nothing. I’ve seen no studies that show antipsychotics helping with akathisia, but they are known to cause it. It was Kramer’s citing of the Osheroff case in his 2016 book, Ordinarily Well: The Case for Antidepressants that triggered the Merrigan’s Buzzfeed story and several others. His take has been command-V’ed into Truth. 

I’ve searched the web with keywords Osheroff and akathisia, and I have found nothing to suggest that a single MD, PhD, or JD ever clued in and attributed Dr. Osheroff’s pacing  and distress to the use or discontinuation of the tricyclic antidepressants he used and discontinued before going to Chestnut Lodge. In fact very few descriptions of his case mention his use of antidepressants before the pacing, self-neglect, and distress set in. 

Dr. Osheroff’s expert witnesses, among them psychiatrists from Harvard, Duke and Columbia, testified that Chestnut Lodge had committed malpractice by failing to give a clearly deteriorating patient medication known to be effective in cases of serious depression. Gerald L. Klerman, then a professor at Harvard Medical School and director of psychiatric research at Massachusetts General Hospital, called the Lodge’s treatment “criminal … cruel and negligent.” (6) He was right until he said the diagnosis of agitated depression is “bread-and-butter psychiatry” that can be made “usually by a first-year resident.” Well, actually, that’s true. A first year resident would make that diagnosis, if he or she had not been taught to recognize akathisia. He was wrong if he believed agitated depression was what plagued Ray Osheroff.


Akathisia elicits a relatively narrow set of self-reports that should be memorized by anyone who prescribes antidepressants or antipsychotics. Listen for “this is unbearable,” “I can’t take this another minute,” and notice any praying for death while denying suicidality. Unfortunately, such utterances can be taken as histrionics or passive aggression, and offend or anger the prescriber, damaging the patient/prescriber relationship.


Dr. Osheroff’s story is revered as the Immortal Argument for Medicating Depression. In reality, it was (very  likely) a case of the devastating effects of antidepressants and the near-murderous ignorance of individuals who earned the right to prescribe drugs, but did not, for some reason, learn enough about them to recognize all of their effects.

I guess Chestnut Lodge had it partly right. Drugs weren’t good for Dr. Osheroff. They made him much, much worse than he was when he first sought help, long before going to Chestnut Lodge. But the Lodge personnel were wrong to insist that his symptoms had psychological causes and probably wrong to omit drugs from his therapy. Beta-blockers, antihistamines, and benzodiazepines are all considered first-line for akathisia. Resuming the drug he was on before the pacing began was worth a try, too.

How could it happen that no one clued in to Dr. Osheroff’s apparent akathisia? The trial wasn’t carried out in secrecy. It is rarely mentioned without some indication that it was a big deal at the time:

“The most famous legal case involving informed consent to therapy…” (6)

“…the case generated widespread discussion in psychiatric, legal, and lay circles…” (7)

“These titans […] testified on behalf of the physician-turned-patient/plaintiff, Dr Osheroff.” (8)

Among the titans were gents from Massachusetts General Hospital, National Institute of Mental Health, Virginia University Medical Center, and a pioneer for the use of chlorpromazine (thorazine), Donald F. Klein, MD, DSc who, as is fitting, was employed by Columbia University at the time.

Every department of psychiatry in the nation’s medical schools must have been paying attention. No friend or colleague of an expert picked up the phone and said, “Uh, I think there was something else going on with Dr. Osheroff back at Chestnut Lodge…?” And that’s despite his textbook-perfect symptoms and plausibly causative medication history before he got to Chestnut Lodge.   

Am I expecting too much of the doctors? When MedPage, in 2016, lets a doctor ask whether tardive dyskinesia is a symptom of schizophrenia or one of the most reliable effects of antipsychotic drugs I start to think I am. That question was settled for the public at least 30 years ago, and undoubtedly known to the drugmakers 30 years before that. The MedPage article also falsely stated that second-generation antipsychotics don’t cause akathisia. Crikey. Abilify caused it in 25% of patients testing the drug as an adjunct to an antidepressant, and caused abilify_aka“restlessness” in 12% of them. The Food and Drug Administration didn’t bat an eye. In trial subjects taking it for bipolar disorder, the akathisia rate was 19%. Tellingly, no “restlessness” was reported in so-called “bipolar” patients testing as a remedy it for their (usually iatrogenic, antidepressant-induced) symptoms. Were none of them restless, or was restlessness in bipolar patients conveniently attributed to unresolved mania?

MuleWhat does Osheroff tell us? This is what I see: After some experimenting with tricyclic antidepressants, a doctor experiences a life-threatening but common adverse event that is mistaken for symptoms of a psychiatric illness. After his feet blister, ulcerate and turn black, an antidepressant is prescribed, along with an antipsychotic, and his restlessness abates. The antidepressant (and sometimes the antipsychotic) is held up as the hero, when all it did was mop up an antidepressant-induced mess. That’s the case that pinned that pharmaceutical tale on the donkey. 

If you prefer not to be made an ass of, join me in believing the following of Osheroff:

• It’s an indictment of the original drug prescribers, who watched the doctor hurtling into the soul-macerating state of akathisia, and stood at a safe distance wondering when the when the motor would seize.

• It shows the damage done by the inclination to “locate the problem in the patient,” as the Chestnut Lodgers did and which Dr. John Read says is typical of psychiatrists in general. (At least the Lodgers didn’t put it there.)

• If forces us to regard the high-visibility psychiatrists touted for their expertise as ignorant or dishonest.

• It reminds us that expert testimony is elicited to win court cases, not to advance science.

Afterword

I learned from a post on 1boringoldman.com that the astute and conscientious Dr. Bernard Carroll was one of the titans, and he does, in my view, merit the designation. For what it’s worth coming from a member of the peanut gallery, I have read nothing he’s written that led me to doubt his integrity. He seems to be brilliant and perspicacious, too. If he didn’t consider akathisia when reviewing Osheroff’s case, perhaps no one could have. “Akathisia” is not a frequently-encountered word or well-known phenomenon in the present, and if it’s rare now, it was hen’s dentures at time of the trial. It’s tripled its mindshare since then.

akathisia-n-gram

[Trivia: Google trends data, below, searches for “Akathisia” (red) haven’t risen in frequency, but by early 2007, they started tracking “extra-pyramidal” (blue) and “atypical-antipsychotic” (green).*]

googletrends

Although Osheroff’s complete story isn’t the help to the pro-drug crowd that the edited version is, it does have metaphoric value. Relentless pacing over the same ground characterizes the public discourse on the benefits and harms of psychopharmacology. Now the new, convincing, and wrong information in Peter Kramer’s new book has led the intelligentsia and their media heroes back to the pharmaceutical end of the arena. When the day comes that a journalist notices and dares to report that the Osheroff case is hardly an unequivocal recommendation for drug therapy, the educated masses will turn back and head our way again. I do hope they mind their feet. The denial of reality, no matter how comforting or lucrative, doesn’t compensate for the moment when one looks down and discovers that one’s feet have blistered, ulcerated and turned black.

*”Extra-pyramidal” is a class of adverse effects of antipsychotics (especially), antidepressants, and other psychotropic drugs. Often irreversible, extrapyramidal symptoms  include acute and tardive (late onset) movement disorders, including continuous spasms and muscle contractions, motor restlessness with psychic agitation and distress, rigidity, slowness of movement,  tremor, and irregular, often intractable, jerky movements, starting with the oro-facial muscles and sometimes encompassing the whole body. One or more of these is close to inevitable for those who take antipsychotics year after year.


References

1 Before Antidepressants, He Wasted Away in a Mental Institution, The Daily Beast, June 9, 2016, by Tara Wanda Merrigan.

2 Responsibilities and Dispensations: Behavior Science & American Justice, 1998, page 288, by Carl N. Edwards.

3 Psychiatry in Law | Law in Psychiatry, Second Edition,2009, by Ralph Slovenko.

4 ‘A HORRIBLE PLACE A WONDERFUL PLACE,’ October 8, 1989, by Sandra G. Bogqman, Washington Post.

5 Ordinarily Well: The Case for Antidepressants, 2016, by Peter D. Kramer.

6 lnformed Consent to Psychoanalysis: The Law, the Theory, and the Data, 2013, by Elyn R. Saks, Shahrokh Golshan.

7 The psychiatric patient’s right to effective treatment: Implications of Osheroff v. Chestnut, American Journal of Psychiatry, 1990, by G. L. Kerman.

8 A Belated Obituary: Raphael J. Osheroff, MD, Psychiatric Times, 2013, by Sharon Packer, MD.

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