In addition to the physical risks you mention, the subjective experience of catatonia is often terrible beyond description. Delusions may impel someone to believe it is also important or meaningful to exist in that state, but relief from catatonia is rescue from an extremis of psychological torture most are fortunate to never experience. Despite being the most salient aspect of catatonia for those who experience it, I find this is rarely mentioned. Another compelling reason to act quickly to provide relief, even over the objections of the patient.
Yes I agree completely, thanks for bringing this up. I always ask patients who recover from catatonia what it was like, to the extent they remember. Most say it was terrifying.
If I or another family member ever suffer from catatonia, I sure hope our doctor is as caring and knowledgeable as Dr. Greenwald. It pains me to see our streets riddled with individuals suffering from severe mental illness without any treatment. In my opinion, their "freedom" does not add to their quality of life.
The tragic condition in which our country’s mentally ill are living and dying on the streets would persist if every doctor were as good as the Angel Gabriel himself. Our legal system has been twisted into a cruel pretzel; it’s highest ideal, the sacred dignity of the individual, has become a regime which forbids the involuntary care which tortured people need. It’s a nightmare.
Thanks for this detailed and enlightening (to me as a lay person) account of dealing with a catatonic patient in relation to involuntary administration of medication. I hope all doctors are as thoughtful and compassionate. I’m particularly interested in this subject of involuntary treatment, one which has become very fraught and even politicized and is so important. I was a babe in the woods about these issues before my daughter became seriously ill in her early 30’s. I think unless you’ve had first-hand experience dealing with a loved one with serious psychosis and suicidality it’s very hard to grasp the reality of it. To me it is problematic to speak of respecting the “autonomy” of somebody who is literally not herself. I wonder if I believe there’s already an exception in emergency situations? The three times my daughter was brought to the ER by ambulance in a manic psychotic state she was given an antipsychotic. The first two times she was released within a couple of days —after she insisted she wasn’t a danger to herself or others. Early on her psychotic experiences were positive—she experienced ecstasy, she believed that she was being given access to special knowledge. And there was plenty of support for this view online—the anti-psychiatry, anti-“medical model” perspective, seeing mental illness as a social construct, and so on. The first episode happened at a Zen retreat, which may have helped color her interpretation of the experiences. She saw her ability to access to “alternative realities” as a gift, one that is honored in some cultures, where people with “visions” are regarded as special. It’s so difficult to write about these issues without sounding cynically materialistic on one hand or dangerously naive on the other. I’m a child of the 60’s. I read RD Laing and Carlos Castaneda and dabbled Eastern mysticism. But psychosis is not romantic. Untreated mental illness can easily be deadly. And anosognosia (lack of insight into one’s condition) in serious mental illness is a big problem. (See Xavier Amador, “I’m not sick, I don’t need help” on his struggles to keep his older brother with schizophrenia taking his medication.)
Reading this, I felt the privilege of being present with a sensitive, knowledgeable psychiatrist on a case that raises many interesting issues, medical and ethical. Thank you for the view into catatonia.
Most people opinions about involuntary treatment is influenced by the relatively few cases of abuse that are overly amplified by the media and probably by some movies they saw.
It might be true for most people, but the people who feel most strongly usually have personal experience. They might be adding to their case with extrapolations from media, but I can attest that while we're usually not talking Cuckoo's Nest level abuse, experiences that are bad enough to cause (actual, clinical) trauma are not uncommon.
I don't think personal experience is relevant for this discussion. People are rarely objective about themselves, and we should not risk the well being of the society and other patients on the complaints of people who might very well have their opinion colored by the very disease that should have been treated in the first place.
This is a matter for doctors, scientists and on the real abuse cases, police, judges and lawyers.
That the personal experience of people whose personal experience is the primary object of discussion is not relevant is a remarkable perspective. Regardless, I think you'll find that many clinicians share the belief that involuntary hospitalization and medication can be unnecessarily traumatizing. Many of the people who have been harmed retain this belief after attaining wellness or never had a reality distorting condition in the first place. It now seems reasonable to ask you from what relevant or knowledgeable perspective you offer an opinion that you think should be given epistemic priority over the people who have direct personal experience? You'll recall you started by claiming that most opinions about involuntary treatment are based on hearsay.
I see absolutely no medical emergency in the scenario you described justifying treatment without consent. Unless you have hard data on the NNT... Like was there a 50% chance that she would die without medical intervention, from known studies? In the state she was in? Then yes, intervene. But the sense I get is that you've got no data on this, just a gut feeling that she could deteriorate... Like all of us. The solution is to up the observations, monitor closely for deterioration, and if she deteriorates have a low threshold for intervention, if you do then have clear evidence of an emergency situation... (Eg data that there is a 50 percent risk of death) Don't just default to forced medication because you couldn't be bothered doing intensive nursing care.
I assure you, I was not operating off of gut feeling alone (although good clinical intuition is in fact quite valuable). My sense is that you do not have clinical experience with this kind of thing. It is not so easy to “wait until they deteriorate and then when it’s an emergency go ahead intervene.” And besides, that’s unethical. In this case, I would describe the situation as urgent with the potential to evolve into an emergency. Therefore it is just irresponsible to sit around waiting.
Ethics and morality, the constitution and the bill of rights. These, albeit written as rules of conduct, are still fluid and debatable and interpretable. I would lean to the doctor who has a history of experience in this area, and has reviewed the data known up to this date to make a qualified judgement in my case.
Should this, among other psychiatric diagnoses, begin the road of defining one's own wishes as their condition declines? We all have the privilege to determine our own destinies, while in our correct minds, through Advance Directives, DNR/DNI, DNAR, AND, POLST. Is it or could it be possible to approach this population while in a lucid moment to fill out a form announcing their wishes should x, y, and/or z occur during the course of their life. For example, should there be a form for the group of people with schizophrenia or dissociative disorders, etc dictating what they want and don't want should catatonia, along with other known symptoms specific to this group occur?
Many states have some kind of "mental health advance directive" for just this purpose. It typically lays out "If I have such and such symptoms then I consent to me admitted to any of the following hospitals and involuntarily given ABC medicines, but don't give me XYZ medicines, and you [can/can't] give me ECT, and all this is valid for X days." They are extremely useful and more people should have one.
Did you mean to imply that your threshold for approving compulsory care is a mortality rate of 50%? (“My data says you’ve still got a better than 50% chance of surviving this sepsis. No compulsory antibiotics for you!”)
And I'm not rabidly anti involuntary treatment, but I am about using it judiciously, and an emergency life or limb threatening situation needs to be genuinely an emergency, not just a gut feeling that this is too risky.
If you are not "rabidly anti involuntary treatment" then intervention in catatonia should be a slam dunk--if there's any psychiatric situation that calls for it, it's this. Benzodiazepines are a low-risk, reversible intervention that is only needed short term, and are so reliable that a positive response is considered a diagnostic indicator. Catatonia obliterates personal agency (recall we are talking about people who have commonly lost the ability to choose to move their body) and often causes extreme suffering well beyond the realm of ordinary experience. That someone may be experiencing extreme suffering is a relevant risk of non-intervention. That catatonia may damage the brain and predispose to further catatonia, even becoming a chronic untreatable condition, is a relevant risk of non-intervention. There are worse fates than even death or dismemberment. Meanwhile, the risk of treatment, with benzodiazepines at least (for reference, we're talking about giving someone the equivalent of valium or xanax here) is quite low. I am exhorting people who are generally opposed to forced medication to learn more about catatonia before opining on what strikes them as judicious. It is easy enough to find stories of people who feel they were harmed by forced medication--I have one of my own. I am more sympathetic to this perspective than you might guess. But I am doubtful you will find anyone who believes they should have been to left to languish and suffer while frozen in catatonia. As someone with personal experience who wishes people knew more about catatonia, it's frustrating to see this comment thread fill up with people who object to forced medication on principle, are obviously ignorant of the particulars of the situation, and are unwilling to consider how catatonia differs from other kinds of crisis. (It is also frustrating that people with strong political opinions in the other direction are extrapolating from my remarks to people living with other forms of mental illness. No one is ever going to learn a damn thing about catatonia if they keep grafting these comments onto either their abstraction of a patient who is being "abuse[d] in locked facilities" with "chemical restraints" in an "unclean nursing home," or their abstraction of a "violent paranoid schizophrenic" who will be "inevitably processed by the criminal justice system for the commission of some violent crime". Anyway, thanks for trying, Dr. Greenwald.)
Honestly, Dr. I found this post horrific. There is nothing dignified about forcing someone to take meds against their will.
Being a psych patient is degrading and humiliating. That poor woman deserved better. 😢
I dont think I will ever be able to get onboard with involuntary treatment… there is a prominent lawyer named Ellyn Saks. She talks about her traumatizing experiences. She think that everyone should be offered “help” but that if they dont want, its unethical to keep forcing ppl to take drugs.
The last thing I want to see is for Psychiatrists to have more powers to limit freedom. Way too many abuses happen in locked facilities. Chemical restraints, unclean nursing homes, not adequate representation to fight mandates…. I understand you see things differently. But the “help” that you offer freaks me out.
I think that supported decision making and affordable housing would be better than locking folks up in run-down psych hospitals 😢
Thats a good question. And in all honesty? I dont see death as the worst possible outcome. The facility I was at as a teen (owned by UHS) ended up getting shut down for fraud and abuse. It was a dumping ground for foster kids who couldnt find placement.
Between the forced strip searches, dirty scubs, and gross food, there was no “healing” there. It left A LOT of us traumatized. The doctor would come once a day to “round” groups of people (I assume medical students) would walk up to each of us and ask invasive questions. (You had to answer… and with the “correct” answer or they would keep you longer)
There is a reason why involuntary treatment is frowned upon upon by disability rights groups like the ACLU.
Not everyone has the same idea about what “quality of life” is. We dont force diabetics to take insulin. I dont think we should lock up more ppl and drug them with benzos and antipsychotics.
This is why advanced medical directives are so important. I understand that you feel like what you did was ethical.,but you have never considered (or cared) about what the patient wants. To me, a psych ward is a jail by another name. I dont want to go down a path where more ppl are subjected to psychiatric abuse 😥🥺
I am in my late 30s now, but I left that place much worse than coming in…. I never want folks to suffer the way we did…. I am sorry if this came across as rude… but abusing vulnerable populations in facility settings is too easy
I'm sorry to hear you had such a terrible experience. I agree inpatient psychiatry as it is currently practiced in the US has very serious problems and I've written about those in another post. My point in writing this isn't to defend the practice as it is currently implemented, but rather this kind of treatment, when done well and humanely, is a positive good.
Do you have any idea what the treatment of “vulnerable populations” is like at Riker’s Island? For violent, severely mentally ill people living in a paranoid schizophrenic hell? Whose civil liberties have been “protected” so that they are then assured of maximal abuse?
Do you think that the alternative to forced medication is “freedom”? The alternative is a life in prison subject to the tender ministration of gangs, bullies, sadistic correctional officers, and other sociopaths. Please consider that if you treat your personal experience as the universal case then you are helping perpetuate the very misery you hope to lessen.
Please see my comment above, from the perspective of someone who has experienced catatonia. That poor woman indeed--more likely than not she was going through unspeakable hell. Intervening in catatonia is more akin to intervening in status epilepticus (same medicine, even) than it is to the kind of long-term forced medication you're thinking of. The idea of offering affordable housing as a solution to catatonia is just absurd--we're talking about an acute, potentially life-threatening crisis that completely obliterates a patient's capacity for independent thought or decision making. It is far more impairing than "garden-variety" psychosis, there are pretty much no degree of freedom in behavior remaining. The patient often can't even choose to move! It's...kind of like if someone was gripping the back of your head and smashing it into a button labeled "maximal suffering" over and over, but you thought you needed to let them do that because you believed they'd kill your family and possibly end the world otherwise. You'd might try to prevent someone from stopping the head-smasher, but only because you were being more deeply coerced. Giving someone benzodiazepines for catatonia is a short-term intervention that resolves a medical crisis that may otherwise be intractable. It's about getting someone into a position where you can even start to think about treating whatever the underlying condition is, a position where they are able to even begin to think about what kind of treatment they do or don't want. Take it from someone who, most unfortunately, knows. I received treatment for catatonia during an accelerating mood episode that enabled me to get me stable enough to be admitted to an inpatient unit, where I was then functional and lucid enough (though still quite psychotic) to tell my clinicians what medications would and wouldn't be helpful, which they thankfully respected, such that my episode began to resolve. I have my own awful inpatient experiences, my own instances of being medicated over objection to my ultimate detriment. I'm very sympathetic to the idea that patients are not always granted a fair level of dignity and autonomy, but this is not the same caliber of thing.
I think the best model of catatonia is an extreme "freeze" reaction, some neural vestige of an animal playing dead to fool a predator, as laid out in this paper: https://psycnet.apa.org/doi/10.1037/0033-295X.111.4.984 This is consistent with both external observation and subjective report (it's not uncommon to either think you are already dead, believe you are going to die, or in my case that you "have to" die for some ineffable but paramount reason, and as mentioned, it's usually associated with extreme fear) and is the rare explanation of a psychiatric phenomenon with any teleological clarity. Neurologically this probably involves the over-excitation of...something...such that when you either a) support inhibitory processes in the brain via GABAergics, or b) do a "reboot" via ECT, the, uh, thing can relax and some engagement with the environment can occur again. The "thing" in question is probably not a discrete brain region, but something more dynamic, a stimulation pattern carving a deep rut, kind of like a pinball bouncing endlessly between two adjacent bumpers. I'm not medically trained, just an ex grad student, but this is how I tend to think about it. It's possible there is some resemblance to seizure activity involved, but I was invoking a higher-level similarity, in incapacitation of the person, stuck-pattern-ness, and exigency. If catatonia were more similar to epilepsy physiologically we'd probably have a better accounting of it by now!
If it is more intimately related to GABAergic activity then it opens the pathway to medicines like Depakote being useful for catatonia. Whenever I see benzo’s being used for any indication, I always wonder whether someone has trialled valproic acid for the same thing.
No problem, I'm grateful that someone was interested in talking about the phenomenon at hand and not just the politics. (Don't know if you were using the gender-neutral dude/man/guy form but my sex is wrongly assumed often enough that I want to note, I'm a woman.)
I see both sides of the argument. I have a family member who has mental illness. It's not as bad as the patient you described however it's bad. I have thought about this topic a lot and in my opinion, I do not think that a patient should be forced to take drugs. Even if they are mentally compromised. My body my choice because it can become a slippery slope as to who is mentally compromised. Remember lobotomies? Sabrinalabow.substack.com
It is a slippery slope in every direction, toward both over-restrictions on involuntary treatment and overly-liberal use as well. That’s why we need to approach the issue thoughtfully and with prudence.
Since you’ve thought about it a lot, maybe you could help me with this puzzle: when we have no legal mechanism to compel a violent paranoid schizophrenic to take medicine that will extract him from the hell in which he is living (where the medicine itself occurs as one more instrument of torture), and he is subsequently and inevitably processed by the criminal justice system for the commission of some violent crime, at which point we can compel him to do pretty much anything the cruelest fellow prisoner or corrections officer can dream up, have we then been true to our fine principles? Has autonomy and respect for the individual been preserved?
Were the subsequent lorazepam doses administered with the patient's knowledge she was receiving the doses? Or were they secretly administered?
I ask because I recall a study where anxious patients were secretly given diazepam, but the symptom reduction was minimal - it made them tired, but they were still anxious. The 'placebo' arm (open administration of diazepam) however reported robust reductions in ham-a scores.
Ethical discussions aside, I wonder how many psych meds wouldn't work if the patent wasn't aware they were recieving treatment. Words matter: they can make us sad, happy, etc. without any drug being added to our bodies. I doubt 30% of depressed patients will still respond to an SSRI without a psychiatrist saying "this pill will help your symptoms" before prescibing.
Unless it’s a situation where the patient isn’t conscious or is otherwise incapacitated, we don’t give any medicines to them without their knowledge. The placebo effect is indeed strong but in this case the lorazepam effect is real and placebo isn’t really playing a role.
I'll admit I don't know much about catatonia, but it sounds diagnostically similar to psychosis. Does your clock test reliably distinguish between the two? Do catatonics not respond to D2 blockers?
Sorry if this is too off-topic from the original intent of your post.
- "hypothetically, if you gave a catatonic patient 2mg lorazepam but didn't tell them about it, would their symptoms still resolve just as reliably". Yes. There is no "psychological effect" from knowing you're getting the medicine that helps recovery. It's all about getting enough benzos and/or ECT to get your brain "unstuck" from it's catatonic state.
- "I'll admit I don't know much about catatonia, but it sounds diagnostically similar to psychosis. Does your clock test reliably distinguish between the two? Do catatonics not respond to D2 blockers?" Catatonia and psychosis are distinct, however they often co-occur. Catatonia is primary thought of as a disorder of abnormal movements, although altered mentation is almost always a big part of it. Psychosis, on the other hand, while not alway easy to define succinctly, is fundamentally a problem of abnormal perception and thinking. I haven't found any reliable problems with clock drawing in psychotic but non-catatonic patients. Also, very importantly, D2 blockers will make catatonia worse. In fact, they can precipitate malignant catatonia, which is almost the same thing as Neuroleptic Malignant Syndrome, which can be fatal. Therefore if someone is catatonic and also psychotic, you give benzos and/or ECT until the catatonia is resolving and only then start giving antipsychotics.
Thanks for the reply doc. I agree re the placebo effect. I was thinking more along the lines of: how much of the effect came from the drug itself (increased gaba) vs your words as the psychiatrist ("I'm giving you something to help your muscles relax")?
Put another way: hypothetically, if you gave a catatonic patient 2mg lorazepam but didn't tell them about it, would their symptoms still resolve just as reliably?
This isn't a criticism btw - actually a compliment of your ability to tell your patients what they need to hear.
In addition to the physical risks you mention, the subjective experience of catatonia is often terrible beyond description. Delusions may impel someone to believe it is also important or meaningful to exist in that state, but relief from catatonia is rescue from an extremis of psychological torture most are fortunate to never experience. Despite being the most salient aspect of catatonia for those who experience it, I find this is rarely mentioned. Another compelling reason to act quickly to provide relief, even over the objections of the patient.
Yes I agree completely, thanks for bringing this up. I always ask patients who recover from catatonia what it was like, to the extent they remember. Most say it was terrifying.
If I or another family member ever suffer from catatonia, I sure hope our doctor is as caring and knowledgeable as Dr. Greenwald. It pains me to see our streets riddled with individuals suffering from severe mental illness without any treatment. In my opinion, their "freedom" does not add to their quality of life.
The tragic condition in which our country’s mentally ill are living and dying on the streets would persist if every doctor were as good as the Angel Gabriel himself. Our legal system has been twisted into a cruel pretzel; it’s highest ideal, the sacred dignity of the individual, has become a regime which forbids the involuntary care which tortured people need. It’s a nightmare.
I couldn't agree more with this. I hope that there is a *small* correction in the direction of welfare.
Great, illustrative post.
Thanks for this detailed and enlightening (to me as a lay person) account of dealing with a catatonic patient in relation to involuntary administration of medication. I hope all doctors are as thoughtful and compassionate. I’m particularly interested in this subject of involuntary treatment, one which has become very fraught and even politicized and is so important. I was a babe in the woods about these issues before my daughter became seriously ill in her early 30’s. I think unless you’ve had first-hand experience dealing with a loved one with serious psychosis and suicidality it’s very hard to grasp the reality of it. To me it is problematic to speak of respecting the “autonomy” of somebody who is literally not herself. I wonder if I believe there’s already an exception in emergency situations? The three times my daughter was brought to the ER by ambulance in a manic psychotic state she was given an antipsychotic. The first two times she was released within a couple of days —after she insisted she wasn’t a danger to herself or others. Early on her psychotic experiences were positive—she experienced ecstasy, she believed that she was being given access to special knowledge. And there was plenty of support for this view online—the anti-psychiatry, anti-“medical model” perspective, seeing mental illness as a social construct, and so on. The first episode happened at a Zen retreat, which may have helped color her interpretation of the experiences. She saw her ability to access to “alternative realities” as a gift, one that is honored in some cultures, where people with “visions” are regarded as special. It’s so difficult to write about these issues without sounding cynically materialistic on one hand or dangerously naive on the other. I’m a child of the 60’s. I read RD Laing and Carlos Castaneda and dabbled Eastern mysticism. But psychosis is not romantic. Untreated mental illness can easily be deadly. And anosognosia (lack of insight into one’s condition) in serious mental illness is a big problem. (See Xavier Amador, “I’m not sick, I don’t need help” on his struggles to keep his older brother with schizophrenia taking his medication.)
Reading this, I felt the privilege of being present with a sensitive, knowledgeable psychiatrist on a case that raises many interesting issues, medical and ethical. Thank you for the view into catatonia.
Most people opinions about involuntary treatment is influenced by the relatively few cases of abuse that are overly amplified by the media and probably by some movies they saw.
It might be true for most people, but the people who feel most strongly usually have personal experience. They might be adding to their case with extrapolations from media, but I can attest that while we're usually not talking Cuckoo's Nest level abuse, experiences that are bad enough to cause (actual, clinical) trauma are not uncommon.
I don't think personal experience is relevant for this discussion. People are rarely objective about themselves, and we should not risk the well being of the society and other patients on the complaints of people who might very well have their opinion colored by the very disease that should have been treated in the first place.
This is a matter for doctors, scientists and on the real abuse cases, police, judges and lawyers.
That the personal experience of people whose personal experience is the primary object of discussion is not relevant is a remarkable perspective. Regardless, I think you'll find that many clinicians share the belief that involuntary hospitalization and medication can be unnecessarily traumatizing. Many of the people who have been harmed retain this belief after attaining wellness or never had a reality distorting condition in the first place. It now seems reasonable to ask you from what relevant or knowledgeable perspective you offer an opinion that you think should be given epistemic priority over the people who have direct personal experience? You'll recall you started by claiming that most opinions about involuntary treatment are based on hearsay.
This is a terrible, terrible point of view
I see absolutely no medical emergency in the scenario you described justifying treatment without consent. Unless you have hard data on the NNT... Like was there a 50% chance that she would die without medical intervention, from known studies? In the state she was in? Then yes, intervene. But the sense I get is that you've got no data on this, just a gut feeling that she could deteriorate... Like all of us. The solution is to up the observations, monitor closely for deterioration, and if she deteriorates have a low threshold for intervention, if you do then have clear evidence of an emergency situation... (Eg data that there is a 50 percent risk of death) Don't just default to forced medication because you couldn't be bothered doing intensive nursing care.
I assure you, I was not operating off of gut feeling alone (although good clinical intuition is in fact quite valuable). My sense is that you do not have clinical experience with this kind of thing. It is not so easy to “wait until they deteriorate and then when it’s an emergency go ahead intervene.” And besides, that’s unethical. In this case, I would describe the situation as urgent with the potential to evolve into an emergency. Therefore it is just irresponsible to sit around waiting.
Ethics and morality, the constitution and the bill of rights. These, albeit written as rules of conduct, are still fluid and debatable and interpretable. I would lean to the doctor who has a history of experience in this area, and has reviewed the data known up to this date to make a qualified judgement in my case.
Should this, among other psychiatric diagnoses, begin the road of defining one's own wishes as their condition declines? We all have the privilege to determine our own destinies, while in our correct minds, through Advance Directives, DNR/DNI, DNAR, AND, POLST. Is it or could it be possible to approach this population while in a lucid moment to fill out a form announcing their wishes should x, y, and/or z occur during the course of their life. For example, should there be a form for the group of people with schizophrenia or dissociative disorders, etc dictating what they want and don't want should catatonia, along with other known symptoms specific to this group occur?
Many states have some kind of "mental health advance directive" for just this purpose. It typically lays out "If I have such and such symptoms then I consent to me admitted to any of the following hospitals and involuntarily given ABC medicines, but don't give me XYZ medicines, and you [can/can't] give me ECT, and all this is valid for X days." They are extremely useful and more people should have one.
Did you mean to imply that your threshold for approving compulsory care is a mortality rate of 50%? (“My data says you’ve still got a better than 50% chance of surviving this sepsis. No compulsory antibiotics for you!”)
And I'm not rabidly anti involuntary treatment, but I am about using it judiciously, and an emergency life or limb threatening situation needs to be genuinely an emergency, not just a gut feeling that this is too risky.
If you are not "rabidly anti involuntary treatment" then intervention in catatonia should be a slam dunk--if there's any psychiatric situation that calls for it, it's this. Benzodiazepines are a low-risk, reversible intervention that is only needed short term, and are so reliable that a positive response is considered a diagnostic indicator. Catatonia obliterates personal agency (recall we are talking about people who have commonly lost the ability to choose to move their body) and often causes extreme suffering well beyond the realm of ordinary experience. That someone may be experiencing extreme suffering is a relevant risk of non-intervention. That catatonia may damage the brain and predispose to further catatonia, even becoming a chronic untreatable condition, is a relevant risk of non-intervention. There are worse fates than even death or dismemberment. Meanwhile, the risk of treatment, with benzodiazepines at least (for reference, we're talking about giving someone the equivalent of valium or xanax here) is quite low. I am exhorting people who are generally opposed to forced medication to learn more about catatonia before opining on what strikes them as judicious. It is easy enough to find stories of people who feel they were harmed by forced medication--I have one of my own. I am more sympathetic to this perspective than you might guess. But I am doubtful you will find anyone who believes they should have been to left to languish and suffer while frozen in catatonia. As someone with personal experience who wishes people knew more about catatonia, it's frustrating to see this comment thread fill up with people who object to forced medication on principle, are obviously ignorant of the particulars of the situation, and are unwilling to consider how catatonia differs from other kinds of crisis. (It is also frustrating that people with strong political opinions in the other direction are extrapolating from my remarks to people living with other forms of mental illness. No one is ever going to learn a damn thing about catatonia if they keep grafting these comments onto either their abstraction of a patient who is being "abuse[d] in locked facilities" with "chemical restraints" in an "unclean nursing home," or their abstraction of a "violent paranoid schizophrenic" who will be "inevitably processed by the criminal justice system for the commission of some violent crime". Anyway, thanks for trying, Dr. Greenwald.)
Honestly, Dr. I found this post horrific. There is nothing dignified about forcing someone to take meds against their will.
Being a psych patient is degrading and humiliating. That poor woman deserved better. 😢
I dont think I will ever be able to get onboard with involuntary treatment… there is a prominent lawyer named Ellyn Saks. She talks about her traumatizing experiences. She think that everyone should be offered “help” but that if they dont want, its unethical to keep forcing ppl to take drugs.
The last thing I want to see is for Psychiatrists to have more powers to limit freedom. Way too many abuses happen in locked facilities. Chemical restraints, unclean nursing homes, not adequate representation to fight mandates…. I understand you see things differently. But the “help” that you offer freaks me out.
I think that supported decision making and affordable housing would be better than locking folks up in run-down psych hospitals 😢
If someone is clearly in an abnormal mental state and refuses medical attention for potentially life-threatening illness, should we just let them die?
Thats a good question. And in all honesty? I dont see death as the worst possible outcome. The facility I was at as a teen (owned by UHS) ended up getting shut down for fraud and abuse. It was a dumping ground for foster kids who couldnt find placement.
Between the forced strip searches, dirty scubs, and gross food, there was no “healing” there. It left A LOT of us traumatized. The doctor would come once a day to “round” groups of people (I assume medical students) would walk up to each of us and ask invasive questions. (You had to answer… and with the “correct” answer or they would keep you longer)
There is a reason why involuntary treatment is frowned upon upon by disability rights groups like the ACLU.
Not everyone has the same idea about what “quality of life” is. We dont force diabetics to take insulin. I dont think we should lock up more ppl and drug them with benzos and antipsychotics.
This is why advanced medical directives are so important. I understand that you feel like what you did was ethical.,but you have never considered (or cared) about what the patient wants. To me, a psych ward is a jail by another name. I dont want to go down a path where more ppl are subjected to psychiatric abuse 😥🥺
I am in my late 30s now, but I left that place much worse than coming in…. I never want folks to suffer the way we did…. I am sorry if this came across as rude… but abusing vulnerable populations in facility settings is too easy
I'm sorry to hear you had such a terrible experience. I agree inpatient psychiatry as it is currently practiced in the US has very serious problems and I've written about those in another post. My point in writing this isn't to defend the practice as it is currently implemented, but rather this kind of treatment, when done well and humanely, is a positive good.
I understand where you are coming from And yes thank you for acknowledging that it was one of the most traumatic experiences.
Do you have any idea what the treatment of “vulnerable populations” is like at Riker’s Island? For violent, severely mentally ill people living in a paranoid schizophrenic hell? Whose civil liberties have been “protected” so that they are then assured of maximal abuse?
Do you think that the alternative to forced medication is “freedom”? The alternative is a life in prison subject to the tender ministration of gangs, bullies, sadistic correctional officers, and other sociopaths. Please consider that if you treat your personal experience as the universal case then you are helping perpetuate the very misery you hope to lessen.
Cogent. And correct.
Please see my comment above, from the perspective of someone who has experienced catatonia. That poor woman indeed--more likely than not she was going through unspeakable hell. Intervening in catatonia is more akin to intervening in status epilepticus (same medicine, even) than it is to the kind of long-term forced medication you're thinking of. The idea of offering affordable housing as a solution to catatonia is just absurd--we're talking about an acute, potentially life-threatening crisis that completely obliterates a patient's capacity for independent thought or decision making. It is far more impairing than "garden-variety" psychosis, there are pretty much no degree of freedom in behavior remaining. The patient often can't even choose to move! It's...kind of like if someone was gripping the back of your head and smashing it into a button labeled "maximal suffering" over and over, but you thought you needed to let them do that because you believed they'd kill your family and possibly end the world otherwise. You'd might try to prevent someone from stopping the head-smasher, but only because you were being more deeply coerced. Giving someone benzodiazepines for catatonia is a short-term intervention that resolves a medical crisis that may otherwise be intractable. It's about getting someone into a position where you can even start to think about treating whatever the underlying condition is, a position where they are able to even begin to think about what kind of treatment they do or don't want. Take it from someone who, most unfortunately, knows. I received treatment for catatonia during an accelerating mood episode that enabled me to get me stable enough to be admitted to an inpatient unit, where I was then functional and lucid enough (though still quite psychotic) to tell my clinicians what medications would and wouldn't be helpful, which they thankfully respected, such that my episode began to resolve. I have my own awful inpatient experiences, my own instances of being medicated over objection to my ultimate detriment. I'm very sympathetic to the idea that patients are not always granted a fair level of dignity and autonomy, but this is not the same caliber of thing.
I was going to remark - this is a use of benzo’s I hadn’t heard of before. Interesting that there’s overlap between epilepsy and catatonia.
I think the best model of catatonia is an extreme "freeze" reaction, some neural vestige of an animal playing dead to fool a predator, as laid out in this paper: https://psycnet.apa.org/doi/10.1037/0033-295X.111.4.984 This is consistent with both external observation and subjective report (it's not uncommon to either think you are already dead, believe you are going to die, or in my case that you "have to" die for some ineffable but paramount reason, and as mentioned, it's usually associated with extreme fear) and is the rare explanation of a psychiatric phenomenon with any teleological clarity. Neurologically this probably involves the over-excitation of...something...such that when you either a) support inhibitory processes in the brain via GABAergics, or b) do a "reboot" via ECT, the, uh, thing can relax and some engagement with the environment can occur again. The "thing" in question is probably not a discrete brain region, but something more dynamic, a stimulation pattern carving a deep rut, kind of like a pinball bouncing endlessly between two adjacent bumpers. I'm not medically trained, just an ex grad student, but this is how I tend to think about it. It's possible there is some resemblance to seizure activity involved, but I was invoking a higher-level similarity, in incapacitation of the person, stuck-pattern-ness, and exigency. If catatonia were more similar to epilepsy physiologically we'd probably have a better accounting of it by now!
If it is more intimately related to GABAergic activity then it opens the pathway to medicines like Depakote being useful for catatonia. Whenever I see benzo’s being used for any indication, I always wonder whether someone has trialled valproic acid for the same thing.
Solid paper rec, thanks man.
No problem, I'm grateful that someone was interested in talking about the phenomenon at hand and not just the politics. (Don't know if you were using the gender-neutral dude/man/guy form but my sex is wrongly assumed often enough that I want to note, I'm a woman.)
She deserved to suffer, is what you're saying.
I see both sides of the argument. I have a family member who has mental illness. It's not as bad as the patient you described however it's bad. I have thought about this topic a lot and in my opinion, I do not think that a patient should be forced to take drugs. Even if they are mentally compromised. My body my choice because it can become a slippery slope as to who is mentally compromised. Remember lobotomies? Sabrinalabow.substack.com
It is a slippery slope in every direction, toward both over-restrictions on involuntary treatment and overly-liberal use as well. That’s why we need to approach the issue thoughtfully and with prudence.
Since you’ve thought about it a lot, maybe you could help me with this puzzle: when we have no legal mechanism to compel a violent paranoid schizophrenic to take medicine that will extract him from the hell in which he is living (where the medicine itself occurs as one more instrument of torture), and he is subsequently and inevitably processed by the criminal justice system for the commission of some violent crime, at which point we can compel him to do pretty much anything the cruelest fellow prisoner or corrections officer can dream up, have we then been true to our fine principles? Has autonomy and respect for the individual been preserved?
I think if you are a danger to yourself or anyone else then medication may be appropriate.
Were the subsequent lorazepam doses administered with the patient's knowledge she was receiving the doses? Or were they secretly administered?
I ask because I recall a study where anxious patients were secretly given diazepam, but the symptom reduction was minimal - it made them tired, but they were still anxious. The 'placebo' arm (open administration of diazepam) however reported robust reductions in ham-a scores.
Ethical discussions aside, I wonder how many psych meds wouldn't work if the patent wasn't aware they were recieving treatment. Words matter: they can make us sad, happy, etc. without any drug being added to our bodies. I doubt 30% of depressed patients will still respond to an SSRI without a psychiatrist saying "this pill will help your symptoms" before prescibing.
Unless it’s a situation where the patient isn’t conscious or is otherwise incapacitated, we don’t give any medicines to them without their knowledge. The placebo effect is indeed strong but in this case the lorazepam effect is real and placebo isn’t really playing a role.
Relatedly:
I'll admit I don't know much about catatonia, but it sounds diagnostically similar to psychosis. Does your clock test reliably distinguish between the two? Do catatonics not respond to D2 blockers?
Sorry if this is too off-topic from the original intent of your post.
To answer both your questions:
- "hypothetically, if you gave a catatonic patient 2mg lorazepam but didn't tell them about it, would their symptoms still resolve just as reliably". Yes. There is no "psychological effect" from knowing you're getting the medicine that helps recovery. It's all about getting enough benzos and/or ECT to get your brain "unstuck" from it's catatonic state.
- "I'll admit I don't know much about catatonia, but it sounds diagnostically similar to psychosis. Does your clock test reliably distinguish between the two? Do catatonics not respond to D2 blockers?" Catatonia and psychosis are distinct, however they often co-occur. Catatonia is primary thought of as a disorder of abnormal movements, although altered mentation is almost always a big part of it. Psychosis, on the other hand, while not alway easy to define succinctly, is fundamentally a problem of abnormal perception and thinking. I haven't found any reliable problems with clock drawing in psychotic but non-catatonic patients. Also, very importantly, D2 blockers will make catatonia worse. In fact, they can precipitate malignant catatonia, which is almost the same thing as Neuroleptic Malignant Syndrome, which can be fatal. Therefore if someone is catatonic and also psychotic, you give benzos and/or ECT until the catatonia is resolving and only then start giving antipsychotics.
Thanks for the reply doc. I agree re the placebo effect. I was thinking more along the lines of: how much of the effect came from the drug itself (increased gaba) vs your words as the psychiatrist ("I'm giving you something to help your muscles relax")?
Put another way: hypothetically, if you gave a catatonic patient 2mg lorazepam but didn't tell them about it, would their symptoms still resolve just as reliably?
This isn't a criticism btw - actually a compliment of your ability to tell your patients what they need to hear.
Ps here's the study I was referring to:
https://www.thelancet.com/journals/laneur/article/PIIS1474-4422(04)00908-1/abstract