It's beautiful outside and very excited to be doing the podcast episode today. And guess what's on my mind? Guess what I'm excited about today?
Well, you say it's beautiful out. Not here in New York City. I guess the snow did melt a little bit. What do you think? I think those are dinosaurs in the background. Maybe you're thinking about dinosaurs?
Well, that would be a good guess. I often am thinking about dinosaurs, in fact. Yes. Yeah, I often am. Let me move my chair so you can see the more. I got more dinosaur pictures that you can't see. I often am thinking about dinosaurs, but I'm actually thinking about something other than dinosaurs today. So, yeah, yeah.
What is that?
I am thinking about the famous case of Chestnut Lodge. Have you heard about that Chestnut Lodge thing?
Is that the ski house? It sounds like a quaint little ski house. But no, no. I think that's that old-timey hospital.
It is. Yes, that famous old-timey hospital that had the gigantic lawsuit in the late 1970s. And that lawsuit is something that really shaped the history of psychiatry in a very big way. Have you heard the story about Chestnut Lodge?
No, I'm curious as to why you're bringing it up. We're supposed to be a TMS podcast. So, yeah, tell me a little bit more about this story.
Yeah, yeah. And now that you mention this, I really have become fascinated by the Chestnut Lodge story. Exactly because it directly relates to the modern day situation with TMS But so I promise we're going to circle back to the topic of TMS But it might take us a little while to get there But the story of Chestnut Lodge I think is fascinating and instructive And it's just a good story too, you know So yeah, I'm very excited about that
Well, yeah, I'm excited to see how you connect it. Why don't you tell us a little bit about the story?
Yeah. So the story started with a guy named Raphael Asheroff. So Raphael Asheroff was a man roughly 40 years old, give or take. He lived somewhere in the Northeast where the weather sucks right now, you know. So he lived somewhere in the Northeast. He was a successful man. And Suddenly, he got a really severe spell of major depression. And it wasn't just regular depression. It was a very bad spell.
And it was bad enough that he had to be hospitalized. And he was hospitalized in a kind of a high-end... Prestigious Psychiatry Hospital called Chestnut Lodge which was I think in Rockville, Maryland I think is where it is and the thing that makes this a little more interesting or at least An interesting twist to this story is that Rafael Osheroff, he was not Mr. Osheroff, he was Dr.
Osheroff.
A nephrologist, I believe.
Exactly, right. He was a kidney specialist. And I got to tell you right now, I'm trying to think of urine jokes to go along with that, and I can't quite come up with one. But yeah, so... Setting that aside temporarily. But yeah, he was a nephrologist and a successful nephrologist with dialysis centers all over the country, with a chain of dialysis centers in the area.
Big moneymaker.
Yeah, I would assume so. Yeah, so I assume that this guy was successful, had a lot of money, probably worked really hard, but suddenly he had this horrible, horrible spell of depression. And he became a psychiatric patient in a hospital called Chestnut Lodge. And Chestnut Lodge, again, was a prestigious place. Like if you were rich or if you were a celebrity, you know, you might end up in Chestnut Lodge because that was the place to go.
Yeah, a nephrologist, we assume he probably had a lot of resources, probably knew what good care was. So he probably chose one of the top treatments.
Right, I would think so. And he probably had a psychiatrist friend or he probably had connections. So he probably knew where the place to go was. He probably knew what was the really good place you should go to. Yeah, one would think. So how do you think things went when he went to Chestnut Lodge?
I feel like one of the big benefits of being a doctor is you have the connections. Like if one of my family members has something go wrong, then I text my friend and say, hey, give me a good connect. So I'm assuming as a nephrologist, he got really good care.
That's what I would have assumed, too. I would have assumed that. Yeah, similar for me. Like if people need something, they text me and say, hey, Steve, do you know a good specialist and such and such? But yeah, I would assume things would go well, but they did not. They did not go well there. And what happened is that in this particular hospital, so remember, this was 1979, I believe.
Yeah. The Treatment He Got Consisted Entirely Of Psychoanalysis And So He Got Which Was A Little More Normal Back Then Than It Is Now You Know So It Wasn't I Think Right Now These Days That Would Be Considered A Weird Approach To Only Do Psychoanalysis I think back then it was would be considered less weird but but yeah so it was 1979 and he would get intensive psychoanalysis like two long sessions of psychoanalysis every day and he was there for week after week after week and as it turned out he did not improve he just got worse mm-hmm he just got worse and worse and And he was actually there for a whole seven months, seven months.
And during that time, he was not just depressed, but he was miserable. It was one of those, sometimes we see patients with depression who have sort of an agitated depression where they have a lot of restlessness and misery and ugh, you know, and he had a low appetite. So he lost a whole bunch of weight. He was losing weight. Going Downhill And Just Getting Worse In Spite Of World Class Leading Edge Psychoanalysis So The Psychoanalysis Was Just Not Working For Him And He Was There For Seven Months So So So Any Idea Do You Know How That Hospitalization Ended How Did He End Up Getting Out Of The Hospital
Well, I'm curious, but what's interesting to me is comparing that to today, where now, because of insurance, the goal of hospitalization is one week. And a lot of patients come into the hospital and they're like, I expected intensive therapy. And it's like, no, for now, mostly you get a medication and then you're locked in the psych ward for the rest of the day. So that's a sharp contrast.
Yeah. Yeah.
Tell me how it ended up
Yeah, yeah, yeah, super sharp contrast, yeah, but yeah, so the way it ended is, so he wasn't improving at all, and while he was in the hospital, he lost his marriage, he lost his career, I presume his big bank account was getting drained, I assume he was probably running out of money, and he lost custody, he lost legal custody of his own kids during that long, yeah, ouch, during that long hospitalization, and what finally happened is he got he got rescued he got he got someone else came to the hospital and pulled him out and that other person was his mother oh it's a nice story yeah it's a nice story yeah but I mean it's a beautiful story but so so this is a guy he's 40 years old he's a successful doctor and mom mom rescued him so what's that
It's ironic that after seven months of therapy, like mom came to the rescue. I feel like that might have been maybe a reenactment of some sort.
It might have been. Yeah. Yeah. And that's a great, you know, we got to do a podcast on psychoanalysis later on. Let's definitely do that. That would be an awesome topic. But, but yeah, so, so yeah. But yeah, so mom came and rescued him. So shout out to all the moms out there. So, and it must have been humble. Yeah. Yeah. Hey moms Yeah So yeah So Yeah So It must have been humbling For this Successful 40 year old doctor To have Mommy come Take him out of the hospital But that's what happened That's exactly what happened Mom rescued him Took him out of the hospital Yay mom And brought him to this Other hospital Called Silver Hill In Connecticut And I know We've heard of that That hospital's still there Yeah I believe So So they brought him to Silver Hill Hospital And so when he got to Silver Hill Hospital, as I understand it, that was like not a fancy place.
It was like, I guess, just a regular hospital, a perfectly good hospital, but just a regular hospital. And when he was there, his treatment was different. When he was there, the psychiatrist there kind of shrugged and gave him Elevil and Thorazine for his depression. Which were, you know, pretty common medications back then. And with those medications, he had a gigantic prompt improvement. Wow. He got better. He got better very quickly.
He left and got back on with his life.
With some things left in the dust.
With a lot of stuff left in the dust. Yes, yes. So the next chapter of this story is that he ended up filing a lawsuit. And normally, you know, I would kind of cringe at the prospect of psychiatrists getting sued. But For this one, it's like, yeah, I'm on his side. So he sued the psychiatrist and sued the hospital. And part of the basis for that lawsuit was, look, he was in the hospital getting his money drained for seven months.
The things they were doing were not working. Why didn't they offer something else? And why not at least consider Medications. But it turned out at this particular hospital, they did not believe in medications. So it's not just that they emphasize psychoanalysis, but they didn't believe that they actually worked. And as part of the court proceedings, it was shown that when it came out that Dr. Osheroff improved with medications that The defense from Chestnut Hospital was to claim that it wasn't actually the medicines that made them better.
It was the fact that somehow the guy had a better therapeutic relationship with the doctor who gave him the pills. You know, the doctor who said, try this pill. Like somehow saying try this pill was... The magic psychoanalytic thingamajig that made the patient better. And they stuck to that claim.
Interesting. I'm a psychoanalytic fan. I actually don't know your opinion on it, Steve. But the thought of being in a hospital for seven months and being quote-unquote analyzed while your life melts away is a circle of hell, in my opinion. That's not good treatment.
Right, absolutely. Yeah, yeah. And I would assume that almost all analysts would agree with you. Yeah, absolutely. But I think things were different back then. I think things were different back then because a lot of people just really deep down could not believe that something other than psychoanalysis would work.
Yeah. So what was the result of the court case? And then what's your take on it?
Yeah, yeah. So the result, I think it was actually settled out of court for an undisclosed amount. But basically, the gist of it was Dr. Osheroff won and Chestnut Lodge lost. And that court case changed the landscape of psychiatry forever. Partly because psychoanalysis was sort of put on trial and people were maybe less enthusiastic about psychoanalysis. But also, even more importantly, that there is more of an emphasis on patients getting to choose among different treatments.
So I think if you come away from this with the idea that psychoanalysis is bad, that's not the point at all. But I think the point is, If one treatment is not working, then how about another treatment? Because different things work for different people. Different things work for different people. Yeah, yeah.
Yeah, it's interesting. Sorry, I'll let you finish.
Oh, no. Go ahead with your thing. Yeah.
Yeah, it's easy to walk away with simplistic interpretations. Like you said, psychoanalysis is bad, medication is good. Mm-hmm. But if there's one thing I've learned in psychiatry, it's you need to have a ton of different lenses on things. You know, and sometimes psych analysis is the best way to view the patient. It's the right lens. It's the thing that helps them. Sometimes medications is the right lens.
We need different lenses. We need different treatments. And what's appropriate for a patient is different. If you have a hammer, everything looks like a nail. In my opinion, a psychiatrist should be a Swiss army knife.
Yeah.
Yeah.
Yeah, yeah, Swiss Army Knife. Yes, absolutely. Yeah. And I think so. Or at least to be able to believe that something, yeah, to be able to broaden their mind a little bit that there are things other than the thing they're an expert in that might work.
Absolutely. And I get annoyed at anyone who thinks that they're Their modality is the right one. I remember being on inpatient and getting collateral from a patient's analyst, and the patient was floridly manic. And the analyst was like, oh, they really need to work through their mother complex. And it's like, come on. This patient is bipolar with psychotic features. This isn't a mother complex. And then the flip side is all the time I see practitioners where it's like, I tried this medication, this medication, this medication, this medication.
What medication should I try next? It's like, come on, people. You need to have a bigger lens on these things and acknowledge it's not medications work or analysis works or certain treatment works. Yeah, it's This is the fun part of the job is knowing the differences.
Yeah, exactly. Exactly. Yeah. Yeah. And I think so. So the way I connect this to TMS is, is, you know, think about this guy here who's getting, you know, old fashioned psychoanalysis for months and nothing, nothing wrong with psychoanalysis, but it did not work for this guy. And medications had been around for at least 20 years at this point. I mean, medications were not controversial. There is an abundance of evidence that medications worked.
It was no longer reasonable to think that medications didn't work for anybody. It was no longer a reasonable position to think that medications don't work. But they still believed that. And so all these people were trapped in this system where they were suffering, suffering, suffering because doctors didn't believe in medicines, you know? So what do we got now? What do we got now? You know, we have about one out of three patients do not improve with conventional treatment, like even with good psychotherapy, good medications.
Still about a third of people don't get better with that. You know, but what, what do they get better with? Well, you know, not often, very, very often they will get better with TMS. So how many people right now are trapped getting one medicine after another from their psychiatrist and the psychiatrist doesn't believe in TMS or has never offered TMS or, you know, somehow it just never comes up.
You ever heard the quote, time is a flat circle?
No, I have not heard that. Time is a flat. Time is a flat. I don't even get that. I don't know.
I think it's from Nietzsche and then the show True Detective the first season which is really good started out all like spooky and mysterious and Russ Cole the main character said it and for some reason I just associate with the fact that history repeats itself like things just there's an eternal recurrence that things just happen over and over and over again and it's funny that we don't learn from history the same things happen in different forms And I think what you're describing is that 30 years ago, there were some dinosaurs, linking it back to the beginning, who thought that psychoanalysis was the only thing that worked and people weren't paying attention to the new stuff coming out.
And now that the new stuff came out, it's become the norm. It's the air we breathe. And everyone's using medications. And we have these ridiculous scenarios of people having tried 20 medication trials and they see a new psychiatrist and they say, hey, maybe the 21st will work. They're making the same mistakes that we made 30 years ago, just in a different modality.
Exactly right yes yes yeah that's exactly it and I think that the thing that's even more interesting about that is you know because I think when I first heard about this Chestnut Lodge case what I thought and I ended up being wrong but what I thought is Wow, what a bunch of morons in the late 70s, early 80s. How could anyone make that mistake? They are so stupid.
I'm glad we live in an enlightened area where we're not that stupid anymore.
God, I'm so much better than them.
Yeah, exactly. I will sit here and revel in my superiority. Thank you very much. But you know, we're just as stupid now as they were back then. We have learned nothing.
I think we're stupider, but...
Yeah, maybe stupider. Exactly. Yeah, we're not just dumb. We're dumb and dumber. So I think psychiatrists are making exactly the same mistake now. And I guess since you and I do a lot of TMS, it is so obvious to us. We see all the time. We see patients who... would have a really big chance of getting way better with TMS and they're seeing a good psychiatrist, but the psychiatrist has not wrapped their head around something different.
They're so enamored with this idea that depression is caused by like a chemical soup. You know, they think of the brain as a chemical soup, you know, serotonin, norepinephrine, dopamine. So the idea of something different like TMS is something that they cannot grasp. And But I kind of get it. I kind of see why they have trouble grasping that. Can I tell you a story? Can I tell you a story about that?
Absolutely. Yeah, yeah. So on the one hand, here I am being holier than thou about like, oh, I get this TMS thing and they don't. But I got to make a confession. I got a confession to make, which is this. So when I started doing TMS in 2013, right? So I was betting my whole career on this TMS thing. So you would think that I would believe in it way more than other people did.
But so I started giving people TMS. The first patient I treated did not improve. The second patient I treated had an amazing breakthrough response. Went from miserable to totally okay. And it was amazing. It was shocking. But When that happened, my first instinct was to say, was to think to myself, no way, no, no, that can't be, that can't happen, you know? So I had my own disbelief at first, you know?
So, you know, so maybe I'm not that much better than everybody else.
Yeah, and to go back, you mentioned that practitioners think depression is a neurochemical soup. And to give a little bit more credit, because I started doing TMS only a year ago, and it's not that I didn't – I had no exposure. So I graduated in residency – Let's see, 2023, I think. And I had zero exposure to TMS. To me, the TMS was like a multiple choice answer on the boards that like was very obscure.
And I associate it with ECT. I didn't. So it's not really until you see it being used that you can kind of appreciate it. And to give the thing I will say that grinds my gears with TMS is Now I see all these TMS bravado clinics open up. And on LinkedIn, I see people like, I think we're going to make the same mistakes again with TMS and interventional treatments because I see people acting like this, this is the cure for everything.
and that TMS is the thing. And all those, like we had it wrong with the medications. TMS and Spravato is what it is. And it's just making the same mistakes in that, no, no, no, no. We need a nuanced view. We need to look at history. We need to look, psychoanalysis, therapy absolutely has its place. Medications absolutely has its place. And TMS is now in the process of figuring out its place.
And when I see nice, shiny advertisements and people saying, 99% remission. That definitely gives up my bullshit meter of get these marketers out of psychiatry. So I definitely have an aversion to seeing that and I do see that with TMS. So I appreciate people who are annoyed by it and think it's just big fancy machines and a lot of money.
Right. Oh, exactly. Right. Yeah, yeah, yeah. And I have a very similar viewpoint, you know, because I know there's psychotherapy, there's pharmacology, and now there's TMS and other kinds of neuromodulation. And I'm a big fan of the neuromodulation, but I try to make sure that's not the only thing I believe in. It's just my personal niche. It's the thing that I do. I know other people do other things that are also good, but it's the thing I do.
I think in the big picture historically, psychiatry was largely psychoanalytic and psychodynamic. Then it was pills and chemicals. Now it's... and the new one is neuromodulation. So it's kind of psychiatry 0, psychiatry 0, and now it's psychiatry 0. And psychiatry 0 is well underway. You know, TMS was FDA approved almost 20 years ago, 18 years ago to be exact. It's We're recording this in 2026. It was FDA approved in 2018.
2008. Sorry, 2008. And so it's not that new, but psychiatry has been very slow, very weirdly slow to pick it up and to pick up the football and run with it as they should.
It's crazy because sometimes I'll bring up TMS and people have that response that I mentioned of like, oh, that's just the moneymaker. And it's like, have you looked at the data? on TMS like it's good and I had a similar story to yours and I'm sure anyone who does TMS had this where you know there's a patient that failed 20 medications and you kind of go through and there's just absolutely everything on it they failed ECT and they come in and get TMS and unfortunately you know I've developed a mindset of like this person's not getting better you know they failed every treatment yeah sure we can another medication but like Yeah, yeah, yeah, yeah, yeah, yeah, yeah, exactly.
Yeah, so hopefully the world will catch up, but I think it's going to take a while, and I think, you know, just as humans, you know, psychiatrists, you're going to have a lot of cognitive inflexibility, and, you know, maybe we just need the older generation to die out before things get better. I don't know.
Or we just need a podcast.
Or we just need a podcast. Okay, we'll do that one. A boat, a little boat, you know. Yeah, yeah. But yeah, that's a great topic Any other comments to end it? I don't think so You know that I think Just one thing is Later on, not today, but later on Let's do a podcast about psychoanalysis I think that would be a great
podcast Can you give us a sneak peek? I'm curious, I don't know your views on psychoanalysis
Oh yeah yeah I you know I went to a training program that was kind of like started out as the rebellion against psychoanalytic theory so yeah I am I am I'm not I'm not a fan of psychoanalytic theory so yeah yeah so so I think I think that would be a great I mean partly I don't know much about it you know so maybe there might be some psychoanalytic reason that I'm not not knowledgeable about psychoanalysis I don't know what Thanks for being here, everybody.
And I hope you enjoyed the show today.
And if you didn't enjoy the show, then just remember that suffering builds character. So you're welcome. Thanks, Dr. Harvey. Thank you, Dr. Malzberg. Talk to you later.
All right. Bye-bye.