Ordinarily Well: The Case for Antidepressants

9

Interlude

What He Came Here For

WHEN I SAY, in a lecture or conversation, that nearly two decades after the discovery of imipramine it was not unusual to meet hospitalized, profoundly depressed patients who had never been offered medication, listeners object that I must be mistaken. But the adoption of antidepressants was far from uniform. If evidence is needed, it abounds in the documents surrounding a famous legal confrontation, Osheroff v. Chestnut Lodge. At issue was a treatment that took place in 1979.

Raphael Osheroff was a kidney specialist and an entrepreneur—he owned dialysis centers—who suffered from anxiety and depression. Shortly before he turned forty, Osheroff became depressed and was treated with psychotherapy and tricyclic antidepressants, like imipramine. He improved, but only moderately, so he lowered his own medication dose, then deteriorated, and signed in to Chestnut Lodge, a psychiatric hospital in Rockville, Maryland.

The Lodge had hosted leading midcentury American psychoanalysts, such as Frieda Fromm-Reichman and Harry Stack Sullivan, and Osheroff’s treatment proceeded along analytic lines. He slipped further, losing forty pounds or more and becoming so agitated—he paced constantly—that his feet needed medical attention. Despite questioning by a consultant hired by the family, Osheroff’s doctors continued to withhold medication.

In 2012, Ray Osheroff sent me a transcript of a treatment planning meeting from early in his stay. It shows the ward staff discussing suicide risk. A psychiatric aide said, “We are very concerned about him because when he looks like he is depressed, he probably is really depressed and the nursing staff feels like we really have to watch him closely!”

In contrast, the ward administrator put Osheroff’s problem in psychological terms:

He asked to be put on medication but I told him that it would interfere with what he came here for! I told him that he needed every neuron to absorb what we are telling him here and that medication would interfere with that. I told him that if his pacing got out of hand we would have to wrap him up in a cold wet sheet pack! The social worker told us that his agitated behavior was reminiscent of the obnoxious conduct that his father had indulged in.

Osheroff explained that he had a contract worth hundreds of thousands of dollars annually that could be voided if he did not return to the office within six months. A doctor at the Lodge scoffed at the deadline: “This business that he created was a giant breast that was going to restore the scenes of adoration that he had with his mother!” The staff anticipated a hospital stay of at least three years, to rework Osheroff’s personality.

Osheroff lost control of his business. His marriage ended. After seven months, a friend had Osheroff moved to another hospital, Silver Hill, in Connecticut, where he received antidepressant and antipsychotic medicines. He improved in three weeks, was discharged in three months, and returned to medical practice.

Osheroff’s diagnosis was a point of dispute. His psychotherapist claimed to have been treating Osheroff for a personality disorder involving narcissism. A dissenting clinician had emphasized the depression, as had bills sent to the insurer. Osheroff and his expert witnesses later referred to psychotic depression, the condition now generally treated with the antidepressant-antipsychotic pairing.

Osheroff sued Chestnut Lodge for negligence, saying that medication would have spared him lost income.

For psychiatry, Osheroff v. Chestnut Lodge was the case of the decade and arguably the half century. It might as well have been Pharmacotherapy v. Psychotherapy. Eminent authorities appeared for each side. Witnesses for Osheroff testified that there was no objective evidence that psychotherapy worked for either severe personality disorder or severe depression, while the benefits of medication for mood disorder were amply documented. Gerald Klerman said of Osheroff that the issue was “not psychotherapy versus biological therapy but, rather, opinion versus evidence.” It might be fairer to say that the suit did double duty, since, in Klerman’s view, the facts were all on one side.

They were hard to resist: Osheroff’s agony and his financial loss—and then his quick restoration by medicine. In that context, the therapists’ justifications for their choices sounded misguided and even cruel. The conclusions that Klerman drew seemed to follow. Depression needed to be treated as illness, and expeditiously. Medicine was effective for that purpose. Where doctors ignored research results, patients suffered needlessly.

A Maryland state medical arbitration panel ruled for the plaintiff, the award was appealed to the courts, and in 1987 the case was settled, largely in Osheroff’s favor, before trial. Despite the absence of a court verdict, Osheroff was enormously influential. Hospital administrators understood that their institutions would be at legal risk if their staff withheld medications whose worth had been demonstrated in clinical trials.

If not in its content, in its political effect Osheroff was like Roe v. Wade. A legal process gave a victory to one side in a dispute turning on deeply held, principled views. The result was resentment and a campaign of resistance by believers in the losing cause.

Klerman, who had served as an expert witness for Osheroff, followed up with him. Writing in 1990, Klerman reported that ten years out, supported by psychotherapy and medication, Osheroff had experienced no downturn serious enough to interfere with his work or social functioning.

I contacted Ray Osheroff in February of 2012, when he was seventy-three. He was living in New Jersey with a long-term girlfriend and practicing medicine. He said that he had “gone through bad times” but never again experienced anything like that devastating episode, an experience for which, as he put it, “depression was a wimp of a word.” He added that his career had never fully recovered and that he had experienced harm in his private life as well.

I don’t doubt that Osheroff had a strong personality. On the phone, he sounded irascible—like the kind of person who makes history. (In their discussion, the Chestnut Lodge staff had recognized that the traits they hoped to moderate were ones that had led to their patient’s professional success.) Osheroff had a wide range of reference, a sense of humor, a quick mind, and a sharp memory. He could be poignant.

Osheroff described the course of his depression in the late 1970s. It began with crying spells and panic attacks. Then he entered “a deep, dark tunnel.” He was beyond sad: “What was worst was the absence of feeling.”

Medication restored him. He could cry again. “You are glad to feel sad … You appreciate birds, blue skies, the smell of the grass.” Elavil, a close cousin of imipramine’s, had sustained him for the rest of his life.

Of his time at Chestnut Lodge, Osheroff said, “You were not treated; you were tortured. The literature of torture is most relevant.”

Three weeks after our conversation and one week after his last e-mail to me, Ray Osheroff died in his sleep.

In an advocacy piece written in 1990, “The Psychiatric Patient’s Right to Effective Treatment: Implications of Osheroff v. Chestnut Lodge,” Klerman suggested that the case’s influence should be extended. Malpractice law had been governed by the “respectable minority doctrine.” If a doctor’s decisions were ones favored by even a few recognized authorities—and the psychoanalysts who recommended withholding medication were many—then those choices could not legally be considered substandard care. Klerman argued for discarding the respectable minority rule wherever scientific evidence favored a course of action.

In their discussions with patients, Klerman wrote, doctors should review treatment alternatives, highlighting research evidence—this in an era when some analysts practiced in near silence. Under the standard he proposed, statements such as “Drug treatment is only a crutch”—the example is Klerman’s—could be used by patients against clinicians in legal actions.

To psychotherapists, Klerman’s approach felt like bullying.

Klerman’s paper fomented resistance, but from a weakening sector. In 1980, the American Psychiatric Association had adopted a revised “diagnostic and statistical manual,” the groundbreaking DSM-III. It erased the category “neurosis” and required diagnosis based on checklists of symptoms. Effectively, Hamilton’s take on depression had won out over Kuhn’s, although perhaps more in the public realm (and on insurance forms) than in the quiet of consulting rooms.

Practitioners continued to believe that mechanical assessments were best understood as quick approximations of what doctors could determine through thoughtful contact with patients. Still, Osheroff was a turning point. The settlement’s main effect was through financial coercion, via potential lawsuits, but the case exerted moral suasion as well. The facts were so egregious that they pushed opinion in the direction of three practices that seemed linked: attention to diagnosis, reliance on objective experimentation, and the use of psychotherapeutic medication.

As a side note: I have said that psychotic depression most often responds, as Osheroff’s did, to combination pharmacotherapy, antidepressant plus antipsychotic. In the era of Osheroff’s hospitalization, only clinical lore, and not controlled trials, backed that practice.

I did my residency at Yale in the late 1970s. Two of my teachers, Malcolm Bowers and J. Craig Nelson, were studying psychotic depression. In 1979, just before Osheroff arrived at Chestnut Lodge, they published a case series. In it, the antidepressant-antipsychotic cocktail looked promising. Bowers and Nelson would soon report cases in which antidepressants given singly made psychotically depressed patients’ delusions worse.

If Osheroff’s psychiatrists had gone with what controlled trials showed—antidepressants help depressed patients—they might have done harm. Silver Hill was staffed by Yale faculty. (My friend Alan worked there then.) That’s why Osheroff got effective treatment, because doctors were aware of Bowers and Nelson’s experimental work. In general terms, systematic research legitimated antidepressants, but finally it was the grapevine—case reports, anecdote—that saved Ray Osheroff.



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