A First-Rate Madness

by Nassir Ghaemi

  One man knew them both very well, Joseph P. Kennedy Sr. In a sadly ironic comment made a year into the Kennedy presidency, the father remarked on his son’s luck and resilience:

  I know nothing can happen to him [JFK]. I tell you, something’s watching out for him. I’ve stood by his deathbed four times. Each time I said goodbye to him, and he always came back. In that respect he is like FDR. Because FDR went to the edge, and he came back too. And afterwards he was unique. It’s the same thing with Jack. You can’t put your finger on it, but there’s that difference. When you’ve been through something like that back, and the Pacific, what can hurt you? Who’s going to scare you?

  Their story lines could hardly be closer. A young scion of wealth, marked for glory, is almost felled by illness, and in the process changes for the better. The key difference between them is that whereas Roosevelt was granted more years as president than any other man, Kennedy was given, as was said in his memorials, many gifts from God, except length of years.

  But the story is not complete: there is another lesson here beyond the resilience of hyperthymic personality. There are the steroids. The drugs that saved John Kennedy’s life would prove a dangerous cure; their mind-altering effects would almost ruin his life, as well as his presidency. Without them, he would never have lived to fail or succeed. With them, he almost failed, and then succeeded spectacularly.

  PART FIVE

  TREATMENT

  CHAPTER 12

  A SPECTACULAR PSYCHOCHEMICAL SUCCESS

  KENNEDY REVISITED

  The story of John Kennedy is instructive in a way that is different from all the other leaders I’ve discussed so far. JFK was treated, with steroids and other agents (amphetamines, barbiturates, cocaine analogues), not just occasionally, but consistently over many years. Those treatments greatly influenced his behavior, for worse and, as we’ll see, eventually for better. So too was the case with an unlikely bedfellow, a leader with mental illness whose treatments (mainly intravenous amphetamines) markedly worsened that illness: Adolf Hitler.

  John Kennedy abused anabolic steroids. He didn’t just take cortisone as a replacement for his body’s normal physiological needs. He abused testosterone-based anabolic steroids—literally the same drugs today used by bodybuilders—for their psychiatric effects. In so doing, Kennedy was changing his moods, probably causing manic and depressive symptoms, in a way that, for a while, harmed his ability to lead. Later, when his physicians got control of the president’s misuse of anabolic steroids, his medications not only kept him alive—they enhanced his function and contributed to his successes.

  Adolf Hitler abused intravenous amphetamines. He had, as we will see, bipolar disorder, with spontaneous severe depressive and manic episodes since his youth. But those mood episodes served him well in many ways, contributing to his charisma and leadership skills, until around 1937, when he began receiving amphetamines as treatment for his depressive periods. Soon he began to abuse those treatments by receiving daily intravenous injections—a practice that continued every day throughout the Second World War, worsening his bipolar disorder, with more and more severe manic and depressive episodes, while he literally destroyed the world.

  The great physician William Osler once said that all medicines are toxic; it is how they’re used that makes them therapeutic. If used in the wrong setting, in the wrong amounts, they always cause harm; they are dangerous; they kill and maim. The art of medicine is about knowing how and when to use medicines—and when not to use them. When doctors give drugs to people with underlying psychiatric illnesses, the potential for harm is exponentially higher. And if such people are political leaders, especially with despotic power, that danger can extend to entire nations, even races.

  So we now need to turn to the effects of treatment for mental illness in leaders. And we’ll see how those treatments can cause great harm, as well as notable success.

  JOHN F. KENNEDY’S presidency had two distinct phases: early failure and late success. The early period (1961–1962) included the Bay of Pigs disaster (when Kennedy tried to implement regime change in Cuba based on an Eisenhower-planned CIA coup), a botched summit in Vienna with Soviet leader Khrushchev (in which Kennedy appeared weak), and retreat in Berlin (where Khrushchev constructed the Berlin Wall). Domestically, Kennedy waffled on civil rights and was unable to get most of his election platform passed by a Democratically controlled Congress. Few knew that throughout this time he suffered from poorly controlled Addison’s disease, which almost killed him, and, as we will see, from the wayward psychiatric effects of anabolic steroid abuse.

  The second phase (1962–1963) included his adroit handling of the Cuban Missile Crisis, a triumphant visit to Berlin, and vigorous support for the civil rights movement. It is this latter Kennedy—peaking in Dallas—whom we mostly recall. Few know that during those last years, Kennedy’s medical treatment had vastly improved; his steroids and other treatments now enhanced his resilience rather than impaired it. These are not the only causes of Kennedy’s successes. But if victory has a hundred fathers, two of the most important for JFK were his natural hyperthymic personality augmented by the manic-like effects of steroid treatments.

  From inauguration day until Dallas, John Kennedy ingested a standard set of daily medications. In 1961, under the care of his personal physician, Janet Travell (consulting with Kennedy’s endocrinology, urology, surgery, and gastrointestinal specialists), the president took four kinds of daily steroids (including an anabolic steroid, testosterone). Sometimes, when he requested them, he also took amphetamines and barbiturates. Travell, a specialist in muscle spasm who had treated Kennedy for about eight years, frequently supplemented the above treatments with injections of procaine, an analogue of cocaine. These injections helped his pain, but by constantly puncturing his back and buttocks they weakened his muscles in those areas.

  At the same time, on his own and without informing his physicians, Kennedy took mysterious injections from Max Jacobsen, purveyor of amphetamines to a well-heeled Manhattan clientele. When this was discovered by Travell and the official White House physician assigned by the navy, George Burkley, they sought Robert Kennedy’s help. The attorney general reluctantly asked the president to drop Jacobsen’s injections, or at least submit a sample for DEA testing. “I don’t care if it’s horse piss,” JFK replied. “It works.” We now know that Jacobsen’s injections probably included testosterone, amphetamines, and possibly narcotics. (In 1971, New York State investigated the doctor’s injections, found them medically dangerous, and stripped him of his medical license.)

  This was the period when, in physical pain and taking numerous psychoactive treatments of unknown safety, the president almost died. Travell kept up her procaine injections, and the president’s muscles kept wasting away. She also injected an anabolic steroid, methyltestosterone, at Kennedy’s frequent request, while Jacobsen kept injecting God-knows-what.

  At this point, an important and underappreciated event happened in the Kennedy presidency: a medical coup d’état. Burkley and the other consultants joined together and, working with Robert Kennedy, weakened Travell and banished Jacobsen. Muscle injections were minimized and a weekly regimen of physical exercise started under a new specialist. Doses of the president’s drugs were reduced.

  Into 1962, the president became more stable in body and mind. He still took four kinds of daily steroids, and now was prescribed daily doses of amphetamine as well. (He also continued to receive, off and on, antidiarrhea medications, and drugs to prevent urinary tract infections). These low to medium doses of multiple steroids were still sufficient (especially with injectable anabolic supplements) to suppress any natural production of steroids in his body (suggested by gynecomastia, growth of breast tissue, a side effect of anabolic steroids), and to cause steroid-related psychiatric side effects. Few historians have clearly noted that these psychiatric risks were especially high because Kennedy always took anabolic steroids (methyltestosterone initially, later Halotestin)—the
kinds that make athletes sometimes go crazy—not just adrenal replacement steroids.

  This may seem like a lot. It is.

  KENNEDY’S ANABOLIC STEROID USAGE is perhaps the most complex, and most elusive, part of his medical history. (Even in 1966, in her oral history, Travell enumerated all of Kennedy’s daily medications but pointedly excluded any reference to testosterone or its derivatives.) Kennedy routinely requested extra methyltestosterone injections or other extra steroid doses, along with amphetamines, before events like press conferences, state dinners, or even just on busy days. Travell seemed reluctant, but she obeyed the commander in chief and dutifully administered the shots.

  After the medical coup, Burkley switched Kennedy from injections to pills: Halotestin (fluoxymesteron, an oral testosterone derivative) became the anabolic steroid of choice. These days, Halotestin is one of the most commonly abused oral anabolic steroids, especially favored by power lifters. It has nineteen times the muscular effects of testosterone. The doses used by the president (about 10 mg/day) were lower than those used by weightlifters long-term, but athletes take similar doses just before performances to make themselves more “aggressive.”

  The psychiatric effects of testosterone-derived anabolic steroids are known. At least three double-blind, placebo-controlled studies show that healthy people (with no psychiatric or medical diagnoses) given these agents experience significant psychiatric effects—some beneficial (increased libido, increased energy, euphoric mood) and some harmful (anger, aggression, violent thoughts, distractability). Combining these studies, 12 percent (ten out of eighty-four) of healthy people developed enough manic symptoms to reach the severity of a full manic or hypomanic episode. If someone has bipolar disorder or an underlying susceptibility to it (like hyperthymic personality), an even higher rate should occur. Summaries of large clinical populations treated with steroids find a 6 percent risk of severe psychiatric reactions, and 28 percent risk of mild to moderate psychiatric effects. JFK may have had manic episodes, still hidden from historical documentation, or milder manic symptoms, such as heightening of his already high libido. Or maybe, paradoxically, his Addison’s disease protected him from getting too manic on steroids. In studies of people with naturally low steroid levels (as in Addison’s disease), steroids improve mood and cause fewer psychiatric side effects.

  JOHN KENNEDY HAD many reasons to be psychiatrically ill. He may have had a family history of mental illness; Addison’s disease, when severe, itself produces clinical depression; and steroids themselves can cause mania or depression. But after carefully examining the medical records in the JFK presidential archives, I found little medical comment on his mental states. Most records simply do not discuss psychiatric symptoms. There was no documentation that Kennedy ever experienced a clinical depressive or manic episode. However, I found documents that suggest he had at least one instance of depressive symptoms severe enough to warrant medical attention.

  In early December 1962, Kennedy developed another viral cold, with sinus and throat symptoms (“a slight sniffle,” according to his press secretary, Pierre Salinger). On December 11, concerned about mental depression, Jackie Kennedy called both Dr. Travell and Dr. Burkley. Here is the note in Dr. Burkley’s file, with “X” being his notation for the president, and “X-1” meaning the First Lady: “Received a call from Dr. Travell who stated that X had spoken to her and said that he seemed a little depressed. . . . Received a call from X-1 stating that X felt somewhat depressed and that she felt that perhaps the antihistamine drugs were responsible for this. She requested that they be discontinued. . . . I received a second call from X-1 stating that she had called Dr. Boles [Kennedy’s gastroenterologist] in Boston and requested that he supply a medication which would be a mood elevator without the possibility of upsetting the gastrointestinal tract and that he had suggested Stelazine as the drug of choice.” Kennedy then received a small dose of Stelazine—which is in fact an antimanic/antipsychotic, not an antidepressant—for the next three days, after which his infection improved. This brief but somewhat intense period of depression, probably related to his underlying Addison’s disease, is the only available documented instance of explicit psychiatric treatment given to John Kennedy.

  Even if they didn’t cause full-blown depression or mania, Kennedy’s steroids could have caused moderate symptoms of those conditions. If so, the most likely candidate for steroid-induced effects might be the presidential libido. The evidence for Kennedy’s hypersexuality is both medical—recurrent urinary tract infections, chronic prostatitis, and documentation of Enterobacter cloacae infection in June 1961—and journalistic. The most extensive journalistic work is by Seymour Hersh, who draws on the testimony of numerous independent witnesses, including Secret Service agents. According to these reports, the president had many sexual relationships—some brief, others longer, using the White House swimming pool (later filled in by Nixon) as a favored venue, an ironic usage given that contemporary media often reported how his physical exercise regimen involved daily visits to the pool. The president’s schedule tended to have long empty periods in the middle of the day, usually from lunch until 3 or 4 p.m. During those times, he went to the pool, usually with his aides David Powers or Kenneth O’Donnell; the Secret Service kept all (including the First Lady) away, except female visitors, often two White House staffers nicknamed “Fiddle” and “Faddle.” Others known to have had liaisons with the president included Mary Meyer (sister-in-law to Washington Post editor and Kennedy friend Benjamin Bradlee), Judith Campbell Exner, and a White House intern, among others. Secret Service agents also reported that unknown women, presumed to be prostitutes, visited the president, on the road and in the White House.

  I recount this libidinous activity because it is relevant to both hyperthymic personality and steroid-related psychiatric effects. Kennedy’s hypersexuality was not limited to his presidential years, but also occurred in his college and congressional years, before and after marriage. JFK always had a high sex drive, probably related to his hyperthymic temperament, and later strengthened by libido-enhancing medications (anabolic steroids and amphetamines).

  Kennedy’s procaine injections are also a possible source of psychiatric effects. Procaine is similar to—but weaker than—cocaine. In animal studies where rhesus monkeys are offered cocaine or procaine, they prefer cocaine. Yet when given procaine, human cocaine addicts report euphoria and pleasurable feelings similar to those of cocaine. When Kennedy combined procaine with other agents that produce euphoria, like amphetamines and steroids, they all augmented one another, increasing his energy and libido further.

  This is an explosive mix of psychiatrically active medications: four types of steroids (including anabolic testosterone-like agents), amphetamines, intramuscular procaine, and intermittent barbiturates. It is hard to accept, biologically, the claim made by Kennedy biographers that none of these medications, nor the illnesses they were meant to treat, had any impact on the president’s leadership.

  This consensus has been challenged only by Dr. David Owen, the sole physician-scholar to examine the medical records and write about Kennedy’s leadership. In his personal review of Kennedy’s medical records, Owen concluded that two phases can be discerned. In the early years of his presidency, Kennedy’s medications were a mess: the mix was higher in testosterone and frequently changing, as well as combined with Jacobsen’s mysterious amphetamine/testosterone injections. This was the time of his greatest failures. In the second half of Kennedy’s thousand days, though, Owen believes the reduction of Kennedy’s injections and the departure of Jacobsen led to more reasonable treatment, and Kennedy became a more effective leader. Owen’s insight makes medical and historical sense, as we’ll see.

  THE POLITICAL TRANSFORMATION of President Kennedy bears recounting in the context of his steroid treatments and the White House medical coup d’état. A few months after taking office, he faced a proposed CIA covert action in Cuba. When Cuban exiles landed in the Bay of Pigs, however, they were o
verwhelmed. They called for U.S. Air Force backup. Kennedy, who had been assured repeatedly by the CIA and military brass that no such military intervention would be needed, refused. CIA and military leaders were appalled; they had expected him to take the next step when defeat was the only other option. Eisenhower would not have stopped, they told him. (“When you commit the flag, you commit to win,” Eisenhower had said during the 1954 overthrow of Guatemala’s government.) Kennedy was shocked. For months thereafter, while struggling to survive his Addisonian crisis, he kept repeating over and over, “How could I have been so stupid?” He brooded on how the CIA and the generals had duped him. (“Those sons-of-bitches with all the fruit salad just sat there nodding, saying it would work.” “I’ve got to do something about those CIA bastards . . .”)