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JAMA Network Insights
March 17, 2021

Caring for the Patient With Catatonia

Author Affiliations
  • 1Department of Psychiatry and Behavioral Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
  • 2University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
JAMA Psychiatry. 2021;78(5):560-561. doi:10.1001/jamapsychiatry.2021.0096

Catatonia has been known for more than 150 years, but it still confuses clinicians.1 Here, we review 3 aspects of psychiatric practice that are crucial for the optimal care of a patient with catatonia: identification, treatment, and prevention. Catatonia, a psychomotor syndrome, reminds us that the mind engages with the world through the body. Being in the world is always a bodily experience. Mental health is the internal equilibrium that assures a harmonious relationship between body and mind.2 Clinicians make inferences about this relationship through conversation and via observation and examination of the body. Whenever a person does not engage with the world, catatonia needs to be considered.

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    1 Comment for this article
    Catatonia Intervention: Hazards and Hope
    Nancy Burke, PhD | Psychotherapy Action Network
    Authors Stephan Heckers and Sebastian Walther are to be commended for reminding physicians to consider catatonia as an often-overlooked mind-body phenomenon that attests to the interactive relationship between these two not-so-separate realms.1 More concerning are their treatment recommendations, which highlight less-benign interventions while neglecting to mention others that have, for decades, proven useful and even curative in the hands of skilled clinicians.

    Most troubling is the authors’ advocacy of electroconvulsive therapy (ECT), which has been shown in many peer-reviewed studies to be both ineffective and harmful. Although it has been touted as a useful
    technique for suicide prevention, there is evidence to suggest that it is no more effective for that purpose as other treatments.2 A recent peer-reviewed meta-study bemoans the poor quality of ECT research in general and suggests that the majority of randomized control trials that compare ECT to Sham ECT fail to demonstrate its effectiveness. Indeed, the authors of that meta-study conclude that, “/g/iven the high risk of permanent memory loss and the small mortality risk, /the/ longstanding failure to determine whether or not ECT works means that its use should be immediately suspended until a series of well designed, randomized, placebo-controlled studies have investigated whether there really are any significant benefits against which the proven significant risks can be weighed.”3

    Heckers and Walther also recommend the administration of benzodiazepines, both ongoing in refractory cases and for diagnostic purposes. Useful to mention in this context would have been the FDA’s recent admission that these medications can cause dependency in just “several days’” use,4 and have been associated with increased incidence of dementia, as well as other conditions.5 Although the authors decry the harmful, and sometimes catatonia-inducing, effects of antipsychotics, they suggest them for ongoing care in certain cases.

    Overlooked are treatments that have been in successful use for decades,6 that recognize the role of terror in inducing catatonia and other so-called schizophrenic states, and that address these terror states psychotherapeutically. It is hoped that physicians will give these treatments another look and refer catatonia-diagnosed patients to individuals with the specialized knowledge and experience to administer them.

    1 March 17, 2021. doi:10.1001/jamapsychiatry.2021.0096

    2 Peltzman, T, Shiner, B, & Watts, B. (2020). Effects of Electroconvulsive Therapy ono Short-Term Suicide Mortality in a Risk-Matched Patient Population, J ECT, Sep;36(3):187-192.
    doi: 10.1097/YCT.0000000000000665.

    3 Read, J., Kirsch, I., & McGrath, L. (2020). Electroconvulsive therapy for depression: A review of the quality of ECT versus sham ECT trials and meta-analyses. Ethical Human Psychology and Psychiatry, 21(2), 1-40. (Link)

    4 FDA requiring Boxed Warning updated to improve safe use of benzodiazepine drug class 09-23-2020) FDA Drug Safety Communication (https://www.fda.gov/media/142368/download)

    5 Islam MM, Iqbal U, Walther B, et al. Benzodiazepine use and risk of dementia in the elderly population: a systematic review and meta-analysis. Neuroepidemiology. 2016;47(3-4):181-191.

    6 Ver Eecke W (2019) How Does Psychoanalysis Work With Persons Afflicted By Schizophrenia? J Psychol Psychother 9:367. doi: 10.35248/2161- 0487.19.9.367