The Impact of Misdiagnosis and Neglect on Depression in a Correctional Facility

This case study explores the severe consequences of misdiagnosis and neglect in a correctional facility, where an individual with severe depression and catatonic features was left untreated for six months.

ByExpert Institute


Published on February 6, 2024

Depressed prisoner in cell

Case Overview

This case study delves into the unfortunate circumstances surrounding an incarcerated individual diagnosed with severe depression exhibiting catatonic features. Despite a psychiatrist’s initial diagnosis, a psychologist assigned to the patient in the correctional facility misinterpreted their condition.

This misdiagnosis led to a six-month period without medication to treat catatonia. The patient was later transferred to a medical center where healthcare professionals attempted various therapies, including Electroconvulsive Therapy (ECT), over five years to alleviate their catatonic state.

However, these efforts were unsuccessful until antidepressants were introduced. While the patient regained conversational abilities after this treatment change, they had not been mobile for five years. This prolonged immobility resulted in severe muscle atrophy in the lower extremities and both feet stuck in extreme plantarflexion. Their hands were also tightly clenched, unable to flex or extend at the wrist.

Consequently, it was advised that double amputations below the knee were necessary to preserve partial mobility.

Questions to the expert and their responses


How often do you manage patients after they come out of a long-term coma or catatonic state?

As a board-certified specialist in Physical Medicine and Rehabilitation with over 15 years of clinical experience, I frequently manage patients emerging from long-term comas or catatonic states.


Have you ever reviewed a similar case? If yes, please elaborate.

Throughout my career, I have encountered numerous cases involving patients recovering from prolonged periods of immobility for various reasons. Each case presents unique challenges and requires tailored rehabilitation plans.

About the expert

This expert is a highly experienced professional in the field of physical medicine and rehabilitation, with a distinguished academic background that includes an internship at a renowned hospital, residency at Harvard Medical School, and a fellowship focused on musculoskeletal medicine, interventional spine care, and sports medicine. They are board-certified in physical medicine and rehabilitation and maintain active membership in several professional societies, including the Association of Academic Physiatrists. Currently serving as the director of an oncological rehabilitation center for optimal health and function medicine at a major hospital, this expert previously held positions as an assistant professor of clinical rehabilitation medicine at a prestigious medical college and an assistant attending physician at a leading cancer center.

Expert headshot



About the author

Find an expert witness near you

What State is your case in?

What party are you representing?