Regarding Pulmonary Embolism During an Episode of Catatonic Depression

Dear Editor:

The report¹ of pulmonary embolism during an episode of catatonic depression [Psychiatry 2007;4(6):51–56] unjustifiably stated that lorazepam is effective therapy for catatonia. However, this has never been established by long-term study. Studies have reported observations for only a few days. This is analogous to the Tensilon^® (edrophonium) test for myasthenia gravis, in which illness signs and symptoms are temporarily reversed but the medication is useless for maintenance. There has been no systematic long-term followup group study of benzodiazepine efficacy in catatonia. I observe that if a patient with acute catatonia shows complete remission with 1mg/day or less of lorazepam, a stable remission is reasonably likely. With higher doses patients relapse into melancholia, psychosis, or catatonia within a few days to a month. The only long-term followup treatment study of catatonic depression with statistical results used electroconvulsive therapy (ECT).²

Ignatowski, et al.,¹ observed that ECT is not available in many state facilities. Administrative refusal to provide ECT when needed does not make benzodiazepines suitable for the task. The authors state there is stigma surrounding the ECT procedure. However, there is surely more stigma surrounding a patient remaining catatonic because of undertreatment and from being learning-impaired and oversimplistic from high-dose tranquilizers than from achieving remission with ECT. The authors state they have difficulty obtaining informed consent; informed consent is surely easier to obtain in psychiatric facilities that regularly provide ECT. Still, the authors' report is highly constructive because it clearly and irrefutably conveys that in treating catatonia ECT is necessary and irreplaceable, and state psychiatric hospitals that do not facilitate ECT for these patients are harming them. Why can these state hospital administrators forget the basic medical ethic of “Above all do no harm?”

With regards,
Conrad M. Swartz, PhD MD
Professor of Psychiatry (Emeritus) Southern Illinois University School of Medicine