Dr. George Dawson had an outstanding blog post on New Year’s Eve, “The Rights Versus Treatment Debate.”
It reminded me of a special case of medical/psychiatric illness: Catatonia. Catatonia can lead to deadly consequences, which can lead to conflicts between psychiatrists and lawyers. Moreover, it can also affect insurance reimbursement, although I usually didn’t have to haggle with managed care entities about it.
For a brief, informal review of catatonia, refer to my post “Delirium and Catatonia: Medical Emergencies.”
It’s a complex neuromotor disorder that often comes on abruptly, often as a complication of a mental disorder such as major depression or bipolar disorder (manic-depressive illness). It can also appear in the context of medical illness as well, or as an adverse event linked to a certain class of medications known as antipsychotics. The latter is called Neuroleptic Malignant Syndrome (NMS). The syndrome is marked by a number of behavioral abnormalities, including but not limited to the following:
- Being mute or simply repeating what is said
- Being immobile or displaying purposeless agitation
- Displaying motor abnormalities that include the tendency to maintain very uncomfortable postures for long periods of times, called “waxy flexibility”.
Among the medical complications of the disorder are deep vein thromboses (blood clots which can travel to the lungs), dehydration due to inability to eat or drink, kidney failure from the breakdown of muscle tissue in the body, and respiratory failure requiring ventilator support and tracheostomy. Morbidity and mortality are high, especially if the preferred treatment is not administered quickly.
The point is that patients with catatonia can be a danger to themselves and trigger requests by psychiatrists for involuntary orders for psychiatric hospitalization to ensure their safety. Because the behavior of such patients is often bizarre, abrupt, and fluctuating, it can lead to hesitation by lawyers and judges to seek commitments to locked psychiatric units. There is often disagreement about how to treat them.
As a consultation-liaison psychiatrist (CL-P) I often encountered catatonia in the general hospital. I was often called urgently because patients stopped talking, eating, and moving. Sometimes they assumed bizarre postures. One is the pillow effect. The patient lies in bed with his head just above the pillow, often for long periods of time—which looks strange and uncomfortable.
While benzodiazepines (often injectable) can “break” the catatonic spell, the effect can be transitory despite initially looking like a miraculous cure. Often the treatment of choice is electroconvulsive therapy (ECT). There can be resistance to applying this treatment because of stigma around the intervention itself and concern that an underlying medical condition might be the cause of catatonia. It might not make sense to some lawyers that a “psychiatric treatment” could stop the manifestation of a medical illness. Another complication is that some of these patients need a combination of medical support and psychiatric treatment which in some cases might best be carried out in a medical-psychiatry unit. This is a specialized ward which is not available in many hospitals, but offers both acute medical and acute psychiatric care.
Catatonia, whether it’s because of psychiatric or medical causes is an emergency, and a potentially life-threatening condition. As I mentioned, the treatment of choice happens to be electroconvulsive therapy (ECT). Depending on the state code, physicians are often faced with navigating a confusing set of legal opinions about how ECT can be applied in order to satisfy the legal requirements of the mental health code. This can prolong the time it takes to apply ECT and often time is of the essence. The longer it takes to satisfy the legal requirement (civil commitment or establishment of legal guardianship), the higher the risk for medical complications or death from catatonia.
A typical case representative of the issue starts with a patient who presents to physicians with the catatonic syndrome. Because the medical complications can be a compelling simultaneous comorbid factor along with the psychiatric antecedents, or because they can be the major presenting problem in the case of NMS, attention is often drawn to those initially.
What seems to follow is an effort to conceptualize the syndrome as being a consequence of either a medical or a psychiatric disorder. This may be the source of the differing legal interpretations of how to apply ECT. In both cases, the patient is unable to consent for the procedure. Some attorneys and judges, dependent on the jurisdiction, will tell psychiatrists and other physicians that they can proceed with ECT without a commitment order, and that all that is really needed is next-of-kin consent.
Other legal authorities may restrict this permission to situations in which NMS occurs, mainly because it has all the attributes of a serious medical illness which requires emergency treatment. Other authorities extend permission to treat catatonia on an involuntary basis when the syndrome is not due to medications or medical illness but due to psychiatric illness if a commitment process is in progress, but no order for commitment is yet rendered.
Still other authorities insist that both next-of-kin consent and a commitment order are necessary. Add to this the alternative requirement that permission for ECT could be granted by someone with legal guardianship (or in some cases, Durable Power of Attorney for Health Care Decisions), either given by an emergency legal process for the express purpose of getting permission to apply ECT or previously ordered by the court—and the procedural requirements could then become a paralyzing morass of restrictions that delays emergency care of the patient.
The differences in interpretation of some state codes regarding mental health commitments and the dualistic way in which physicians and legal professionals tend to think about catatonia, i.e., “is it medical or is it psychiatric?”, may be two factors that contribute to the logistical difficulties we often encounter trying to treat the condition. The stigma surrounding mental illness and ECT is probably another factor.
When emergency treatment requiring a medical procedure for a more typical medical illness (such as acute coronary syndrome or ACS) is needed, the treatment would typically be done immediately. When emergency treatment for catatonia is requested, legal procedures can go on for many days—while the patient and family suffer. Yet the risk for harm from some invasive emergency treatments for ACS may be significantly higher than the risk for harm from ECT for catatonia. The risk of dying from the complications of catatonia can be very high when ECT is delayed by only a few days. But delays longer than that are not unusual. Many would be outraged at a two-week delay in performing a cardiac catheterization.
If we avoid dichotomizing catatonia as either medical or psychiatric, and instead think of it as a life-threatening emergency for which an effective treatment is available, would that help patients get more prompt access to the intervention? And if that were done, could some state mental health codes change in any way to reflect the change in our conceptualization?
The argument probably is not that simple. The issue of what to do if the patient refuses treatment after treatments have begun once she is able to express a choice remains. Administering ECT for a patient who is unresponsive and who may die without it is not as problematic as deciding how to continue the treatments once the patient begins responding to ECT. Based on the respect for the principle of autonomy, in some jurisdictions current practice and statute prohibit continuing ECT without a court order or court-appointed guardian’s permission if the patient becomes alert during the course of ECT and states a preference not to undergo further treatments. Under some laws, if the patient simply states this preference, she is presumed to retain decisional capacity.
The clinician has few choices: find an alternative treatment the patient will accept voluntarily, seek court commitment, or have a guardian appointed who can decide on the patient’s behalf. The patient’s clinical condition will, in some cases, guide the decision. If the catatonia has completely resolved, meaning a sustained recovery has occurred (although the definition of “sustained” can certainly be debated), it may not be necessary to insist on further ECT. If the catatonia has not resolved, the clinician will need to demonstrate that a decisional capacity assessment reveals that the patient, in fact, lacks capacity regarding the issue of the need for continuing treatment of catatonia.
The aforementioned factor of how to address the change in the patient’s willingness to continue ECT may be one of the reasons why some jurisdictions insist on having a commitment in place prior to starting the treatments in the first place. It may ensure the ability to continue the treatments when needed without a gap in time that may lead to deterioration in the patient’s condition—at the expense of up-front delays in order to get the legal groundwork laid.
Ironically, the up-front delays may in fact lead to the very deterioration in the patient’s condition all stakeholders wish to avoid. Current treatment guidelines indicate early intervention with ECT is recommended for malignant or excited-delirious forms of catatonia. They also point out that those with chronic catatonia usually fail to respond as quickly or as completely to ECT, arguing for “early diagnosis and appropriate intervention” (Bhati, Datto et al. 2007).
If physicians and attorneys could agree on the principle above, then a mechanism for allowing emergency ECT for these patients may be conceivable. It could combine the strategies that authorities may disagree on. One scenario might be permitting emergency ECT on the authority of next-of-kin (NOK) decision alone initially, arguably when it would matter the most regarding the timing of the intervention. This strategy would allow for emergency ECT without making a distinction between medical or psychiatric causes of catatonia, since the morbidity and mortality often are virtually the same regardless of etiology. If the patient recovers completely after one or two treatments, and refuses further ECT, there may not be a reason to file for commitment since catatonia can resolve after very few treatments.
If the patient recovers full ability to respond and chooses to refuse further ECT, but there is reason to doubt she retains full decisional capacity to make rational choices about the treatment, it may be advisable to file for commitment. This would be more likely when the catatonia is due to a severe mood episode, which typically takes more than one or two ECT treatments to effect full resolution of symptoms.
These examples represent only a point of departure in the discussion. The “devil is in the details” to be sure. However, at the very least, these suggestions might allow enough of an intervention to “break” the catatonia early enough and long enough to interrupt what could be a relentless spiral into the life-threatening complications of catatonia.
Bhati MT, Datto CJ, O’Reardon JP. Clinical manifestations, diagnosis, and empirical treatments for catatonia. Psychiatry (Edgmont). 2007 Mar;4(3):46-52. PMID: 20805910; PMCID: PMC2922358.