Aug 4, 2017 - These 96 patients were 62% (59/96) male and 38% (37/96) female. .... patient with a stuporous episode of catatonia had been âawakenedâ with IM ... He went to the unit and saw a 21-year-old female catatonic patient who was immobile in ..... admission the physical exam performed by a nurse practitioner ...
1 Puentes R, Brenzel A, de Leon J. Pulmonary Embolism during Stuporous Episodes of Catatonia Was Found to Be the Most Frequent Cause of Preventable Death According to a State Mortality Review: 6 Deaths in 15 Years. Clin Schizophr Relat Psychoses. 2017 Aug 4. doi: 10.3371/CSRP.RPAB.071317. [Epub ahead of print] PubMed PMID: 28777033.
Supplementary Material
2 1. DESCRIPTION OF KENTUCKY’S PUBLIC PSYCHIATRIC SYSTEM The state of Kentucky is located in the center of the United States and has a population of approximately 4 million people. Most Kentuckians are Caucasians; less than 10% are African-Americans and small numbers of people are from other racial/ethnic backgrounds. The majority of adult patients with severe mental illnesses (SMIs) get admitted to four state psychiatric hospitals. Technically three of them are subject to state laws that forbid electroconvulsive therapy (ECT) on their grounds and one is a private general hospital with a state contract to run a large psychiatric unit that is separate but adjacent to the medical hospital. Two of the state hospitals are currently being managed by contracted health organizations (university or community mental health organization). According to our centralized database containing admissions data, the annual number of different patients admitted to these four psychiatric state hospitals has ranged between 5,556 and 7,106 over the last 15 years. The state also owns a forensic psychiatric unit in the prison system, four hospitals for adults with intellectual disability (ID) and four nursing homes. 1.1. Mortality Review Process All the public facility contracts and/or regulations require that deaths at any of these facilities be reported to the state. Since 2002 a state mortality review process has provided outside review of the deaths at any state facility, in addition to the internal regulatory process at each facility (50). The state mortality review committee is composed of psychiatrists, nurses and pharmacists who have expertise in the subject. During the committee’s 15 years of reviewing deaths, judgments regarding the medical cause of death were made after discussion and they always included 2 or 3 psychiatrists who were present at the meetings. Patients dying after being transferred to a medical hospital for treating medical issues also get reviewed by the committee as long as the patient dies within 30 days after the transfer from the state facility to the medical hospital. As a matter of fact, our psychiatric hospitals do not discharge patients who are transferred to the neighboring collaborating medical hospitals for acute treatment since the
3 understanding with the medical hospitals is that the psychiatric hospital will take the patient back as soon as he/she is medically stable. In 15 years (from 2002 to May of 2016) we reviewed 96 deaths at state psychiatric hospitals. These 96 patients were 62% (59/96) male and 38% (37/96) female. Race was available for 72 patients with 88% (63/72) Caucasians, 11% (8/72) African-Americans and 1% (1/72) other. These demographic data roughly correspond to the admissions demographic data from our published studies including thousands of patients from these state hospitals (51, 52). The mean age ± standard deviation of the 96 deceased patients was 58.3 ± 16.4 years). This is apparently higher than the average age of admitted patients every year, which tends to be in the late 30s (51, 52). Obviously, older patients are at higher risk of death. Over the same 15 years, the committee has also reviewed 538 deaths at other state facilities (the forensic unit at the prison system, four hospitals for adults with ID and four nursing homes). 1.2. Review of Individual Cases and Their Treatments When there is any conflictive issue, the mortality review committee asked the senior author to act as an external mortality reviewer and study all information available, including all medical charts. The 6 cases of patients who died during catatonic episodes were carefully reviewed; extensive description, including many direct quotations from the charts, is provided in Section 2 of this Supplementary Material. All 6 of the deaths appear to be explained by pulmonary embolism (PE). Each case description has 6 sections: prior history, course during the hospitalization leading to the death, description of the death, retrospective diagnosis of catatonia using DSM-5, summary of the treatment with benzodiazepines and ECT, and retrospective diagnosis of PE. Tables 1, 2 and 3 provide summaries of the six patients by focusing respectively on catatonia diagnosis, catatonia treatment and PE diagnosis. 1.3. Limitations on the Implementation of Catatonia Treatments 1.3.1. ECT. State laws do not allow ECT to be given at our state hospitals; therefore, to administer ECT, the patient needs to be transferred to one of the few psychiatric facilities that provide ECT in Kentucky
4 after several weeks of legal procedures. Almost all patients get admitted to our psychiatric state hospitals with a 72-hour court order that approves involuntary hospitalization due to risk to self and/or others. Then the treating psychiatrist negotiates with the patient a voluntary admission or goes to a court hearing usually held on the hospital grounds to obtain an involuntary hospitalization order for up to 60 days. The option of extending this order for another 360 days is available, but judges are becoming progressively more reluctant to approve these extensions. If the patient refuses psychiatric medications, additional legal requirements include a meeting to review the case with other hospital psychiatrists and another court hearing to force psychiatric medications. After medications have failed, if the psychiatrist decides to force ECT, another review of the case by other psychiatrists focused on ECT and another court hearing are required. In summary, forcing ECT on any of our patients usually requires at least three court hearings over several weeks and the patient’s transfer to another hospital. 1.3.2. Emergency use of medications including benzodiazepines. In medical or psychiatric emergency situations that constitute substantial risk for the patient or to others, clinicians are allowed to prescribe an as-needed order including intramuscular (IM) administration without the patient’s (or guardian’s) consent. Almost all patients have an order for psychosis and/or agitation that includes oral or intramuscular (IM) antipsychotics and/or lorazepam, which is used according to the nurses’ discretion. As a matter of fact, nurses gave IM lorazepam to three of our six catatonic patients because they were considered to be agitated and/or psychotic. Intravenous (IV) medications are rarely used in our state psychiatric hospitals. First, our nurses are better trained in dealing with complex psychiatric behaviors but tend to have less training in medical procedures than nurses from medical hospitals. Second, there is substantial risk when IV systems are available in units where other patients can be severely agitated or even violent. Therefore, when the patient needs IV medication, they are usually transferred to the neighbor collaborating medical hospital. Therefore, IV lorazepam is rarely used in catatonic patients at our psychiatric state hospitals, although the
5 senior author has used it a few times, frequently with the help of psychiatry residents who felt competent in managing medical emergencies and who carried out the IV administration. Almost all of the stuporous catatonic patients whom the senior author has directly treated or for whom he has consulted, have recovered after low or extremely high lorazepam IM doses followed by oral lorazepam. 1.4. Limitations in Obtaining Autopsies in Kentucky’s Public Psychiatric System No autopsy was available in 4 patients (Cases 2, 3, 5 and 6) who died suddenly because the family refused autopsy. Our mortality review committee has many times discussed the fact that the number of autopsies in our psychiatric state hospitals is too small (16%, 15/96). There is not much that the committee can do to overcome the barriers to autopsies since they include: 1) family refusal; 2) state law which cancels state guardianship when the patient dies, precluding the possibility that a state guardian could ask for an autopsy; and 3) lack of specific funding for autopsies. The latter provides no incentive for county coroners (many of whom are not physicians), who would need to pay for an autopsy using their departmental budget. 1.5. The Senior Author’s Experience in Teaching on Catatonia in Kentucky’s State Public System The senior author arrived in Kentucky 20 years ago, hired by one of the two state universities with a medical school, to manage the long-term unit for refractory patients of one of these state hospitals. The senior author found that, as in many places in the US (11), practicing psychiatrists at the state hospital thought that catatonia had disappeared and psychiatry residents were taught the same idea. In the senior author’s first year, a catatonic patient, admitted to his long-term unit, responded to benzodiazepines. In his second year, he went to court to force medication and ECT for a catatonic patient who required a nasogastric (NG) tube, and naïvely asked for approval of both forced medication and forced ECT. The forced ECT petition caused great concern and only the forced medication was approved. It appeared that the court had not been asked for forced ECT for many years. Fortunately, the patient responded to IV lorazepam. Many months later and after several catatonic relapses, the court approved the forced ECT without any problem.
6 The senior author’s efforts to educate about catatonia and treat catatonic patients throughout Kentucky’s public hospitals have brought forth many skeptical psychiatrists but were supported by three physicians (see Acknowledgments): a family doctor and two psychiatrists, identified as Convinced Psychiatrists 1 and 2. The efforts to teach about catatonia can be divided into 3 periods. For the initial eight years he managed the treatment-refractory unit in one of the state hospitals. First, he supervised a resident rotating in his unit each month who frequently got exposed to catatonic patients. Second, he asked Convinced Psychiatrist 1 to witness a benzodiazepine treatment of a catatonic patient. Convinced Psychiatrist 1’s prior training included: 1) emergency medicine and 2) a recently completed psychiatry residency before the arrival of the senior author at the academic department. The only acute unit in the state hospital that focused on admitting new patients was managed by Convinced Psychiatrist 1 and another psychiatrist who did not believe in catatonia, Treating Psychiatrist 1. Convinced Psychiatrist 1 was the only psychiatrist at the acute unit when Treating Psychiatrist 1 was on vacation. Convinced Psychiatrist 1 started consulting the senior author for his catatonic patients and, more importantly, those under the care of Treating Psychiatrist 1 when the latter went on vacation. Several times after his vacations, Treating Psychiatrist I saw that a patient was now talking and moving who, before the vacation, had been mute and immobile. One time, after Treating Psychiatrist 1 returned from vacation, the senior author decided to confront him by telling him face-to-face that he did not know how to diagnose catatonia. An autistic patient with a stuporous episode of catatonia had been “awakened” with IM lorazepam during this vacation, but Treating Psychiatrist 1 denied that the patient was catatonic and insisted he was only “autistic”. The confrontation with Treating Psychiatrist 1 did not have much positive effect since the patient in Case 2 died under his care some months later. This patient was partially awakened when a nurse gave her an as-needed order of IM lorazepam 2 mg for agitation. Then, a few hours later, Treating Psychiatrist 1 started clonazepam. The hospital pharmacists reported that Treating Psychiatrist 1 had never previously used benzodiazepines for catatonia, so it is possible that Treating Psychiatrist 1
7 remembered some of the conversation with the senior author. Unfortunately, however, it was too late for the patient, who died in less than three days when she started moving after 3 months of immobility. The second period of catatonia education given by the senior author lasted 9 years; he was a consultant for all state facilities. He was moved from the long-term unit to state consultant by Convinced Psychiatrist 2, who was the clinical director at the state department of mental health. Convinced Psychiatrist 2 had seen a catatonic patient awaken with amobarbital 20 years prior when he was a resident. As state consultant, the senior author spent seven years focusing almost all of his time and effort at facilities for adults with intellectual disability that were under threat of closure by the US Department of Justice. In 2006, there were 4 facilities with approximately 400 long-term beds, but the number of beds was substantially reduced through the years. The senior author reviewed all the charts and personally saw many of the patients who were at these facilities in 2006 or admitted after 2006. In one of these four facilities, Convinced Psychiatrist 2 identified an undiagnosed catatonic patient and consulted the senior psychiatrist. The patient was discharged after improvement with oral lorazepam. In a second facility for adults with ID, Convinced Psychiatrist 2 identified two more cases of catatonic patients underdiagnosed for many years and consulted the senior author. The senior author identified another case in a third facility. Three of these four cases were published (59) and they are the first three published cases of catatonia in adults with ID who were more than 50 years of age. The third period of catatonia education occurred during the past 4 years and has focused on the senior author’s state hospital. He was helped for 2 years by the family doctor who supervised the medical treatment of all patients and who started alerting the senior author when stuporous catatonic patients were not being treated with benzodiazepines; sometimes she started anticoagulation treatment on them. For two years, Convinced Psychiatrist 1 managed the only female acute unit at the hospital conjointly with Treating Psychiatrist 2. As before, when Treating Psychiatrist 2 went on vacation, Convinced Psychiatrist 1 called the senior author to treat catatonic patients. One time the senior author tried to confront Treating Psychiatrist 2. He went to the unit and saw a 21-year-old female catatonic patient who was immobile in
8 bed covered by her menses after a catatonic relapse. The senior author discussed the situation with Treating Psychiatrist 2 and the unit nurse. When the senior author asked if it was normal for a young women to be lying in bed covered by her menses, Treating Psychiatrist 2 denied that the patient was catatonic, implied that the patient was acting for psychological reasons and, moreover, explained that the patient could move if she wanted since she had talked on the phone with her mother the prior day. The unit nurse was 100% sure that this behavior of lying in bed disregarding the menses was not normal for a young woman. Convinced Psychiatrist 1 had ordered a creatinine phosphokinase (CK) in this patient and it was clearly abnormally high after a relapse of catatonic symptoms. Therefore, the senior author asked Treating Psychiatrist 2 if it was possible that CK was elevated for psychological reasons and she then had to acknowledge that was not possible. Convinced Psychiatrist 3 is a prior psychiatry resident who had become an attending in the academic department and worked on the weekends at the state hospital as an on-call psychiatrist. After the senior author found that Convinced Psychiatrist 3 had missed the diagnosis of catatonia in one patient at the state hospital, he contacted Convinced Psychiatrist 3 and sent him a PowerPoint lecture developed for residents to learn to diagnose and treat catatonia. Seven months later Convinced Psychiatrist 3 diagnosed the patient in Case 4 in the state hospital emergency department (ED) and sent the patient to the university hospital. 2. CASE DESCRIPTIONS 2.1. Case 1 2.1. Prior History The patient was a 23-year-old Caucasian male with a history of Paranoid Schizophrenia with no prior hospitalization at the psychiatric state hospitals. He was admitted involuntarily to the psychiatric state hospital with hallucinations, paranoid behavior, inappropriate laughing and non-compliance with psychiatric medications. Additionally, the patient showed catatonic signs, including limited verbal communication and refusal of any fluid and food intake. Medical diagnoses included hypothyroidism and
9 sensorineural deafness. His weight was 89 Kg (196 pounds). On admission, the psychiatrist started risperidone, 4 mg/day. 2.1.2. Course during Hospitalization that Led to Death On day 4 of hospitalization, it is documented that the patient was partially compliant with the scheduled medications. The following day, aripiprazole 10 mg/day was added to risperidone 4 mg/day. No immediate response was seen; in fact, the patient continued to refuse food and fluid intake and was described as “nearly mute and somewhat catatonic”. ECT was considered as a means of treatment; however, the patient’s mother refused this treatment. On day 7, laboratory results were significant for elevated bilirubin (total bilirubin of 2.66 mg/dL; normal range 0.0-1.0), and direct bilirubin of 0.25 mg/dL (normal range 0.0-0.2). There are no records of the patient’s baseline bilirubin or of any prior medical diagnosis consistent with this disturbance. On day 10, risperidone was increased to 6 mg/day and aripiprazole to 20 mg/day. On day 11, a physical exam was normal except for decreased breath sounds in auscultation; a chest X-ray was described as unremarkable. On day 12, the psychiatrist added fluoxetine 20 mg/day for depression and oral lorazepam 2 mg/day for catatonic behavior. His explanation for the treatment was “Appears depressed, I order Prozac 20 mg. Also staff tells me they have given a catatonic patient Ativan. Patient responded well to Ativan. So, I will order a moderate amount of Ativan”. Fluoxetine is an inhibitor of risperidone and aripiprazole metabolism (54). During the course of two to four days after this new medication regimen, the patient appeared to progressively improve, initially feeding himself a little bit and then gradually talking using 2-3 words. Then on day 17, the patient resumed his refusal to eat and drink. At that time, aripiprazole 20 mg/day was increased to 30 mg/day and fluoxetine 20 mg/day was increased to 40 mg/day, but lorazepam 2 mg/day was not changed. Despite these medication changes, the patient continued to appear “muted”, was slow to respond, and showed psychomotor retardation. On day 25, the patient continued to remain “catatonic” and was “eating very little”; risperidone and aripiprazole were discontinued and olanzapine 40 mg/day was then started. On the same day, a nurse documented that the patient appeared to be kneeling for a long
10 period. He was also observed walking with poor balance, leaning to his right side where lower extremity edema was perceived. In the afternoon, the patient appeared in distress with his hands on his chest. When questioned by staff about chest pain, the patient nodded “yes” with his head. He was given benztropine, 2 mg once and was transferred to the ED of the medical hospital adjacent to this psychiatric facility. At the ED, the patient was described as pale, weak, catatonic, and exhibiting a blank stare. His physical exam was remarkable for unexplained tachycardia and hypoxemia (PO2 of 72 mm Hg). He was provided with 2 L of supplemental oxygen. A bilateral venous Doppler sonography showed no evidence of deep venous thrombosis (DVT). The next day, a chest X-ray showed no acute pulmonary infiltrate. The internist concluded that the patient was sedated by psychotropic medication and discontinued lorazepam. The ED discharge diagnoses included acute mental state due to over-sedation, tachycardia, mild hypoxemia, and chronic schizophrenia. After one day of observation, as the tachycardia and hypoxemia had resolved, the patient was transferred back to the adjacent psychiatric hospital. On day 26, the patient was described as having lost 5.9 Kg (13 pounds) since his first day of admission and a dietary consult was ordered. He answered a few questions, using 1-3 words. During the next two days, the patient was “mostly silent” and selectively eating food he liked. 2.1.3. Death Then on day 29 of hospitalization, a medical consult was requested for further evaluation of the right ankle edema and a chest X-ray was ordered. In the afternoon a nurse documented bilateral edematous ankles. In the evening, the patient was found unresponsive by the staff in the bathroom. The patient had no respiration, pulse or blood pressure (BP). Cardiopulmonary resuscitation (CPR) was started immediately and the patient was pronounced dead 65 minutes later. The autopsy report verified the diagnoses of bilateral PE and DVT of right popliteal vein (with early organizing of the thrombosis and fribroblastic reaction at the thrombus-endothelial interface and early neovascularization). 2.1.4. Retrospective Diagnosis of Catatonia
11 The patient met four of twelve DSM-5 diagnostic criteria for catatonia including stupor, mutism, negativism, and posturing. Based on the documented labs, imaging and past medical history, there were no medical conditions, such as neurological or metabolic diseases, which can cause catatonia. At that time, the psychiatric diagnosis was catatonic schizophrenia. In DSM-5 terminology, it would be Schizophrenia with Catatonia. 2.1.5. Treatment with Benzodiazepines and ECT As far as we know, the patient’s catatonia lasted throughout the 29 days of his hospital admission, but there is no information on how long he had catatonic symptoms before admission. In this case, the psychiatrist considered treatment of catatonia with ECT but it was refused by the patient’s mother. Therapy with lorazepam 2 mg/day was started on day 12 with a partial response, indicating a suboptimal dose. No further dose increase was considered, and in fact, the benzodiazepine treatment was discontinued by the internist due to the concern about sedation on day 24. 2.1.6. Retrospective Diagnosis of PE Based on Malý et al. (49), this patient had three risk factors for venous thromboembolism (VTE) including immobilization, dehydration and treatment with antipsychotics, which provided a mild risk. The autopsy report verified PE and DVT. 2.2. Case 2 2.2.1. Prior History The patient was a 44-year-old Caucasian female who was involuntarily admitted to a state psychiatric hospital with an initial diagnostic impression of “Major Depressive Disorder” with Psychotic and Catatonic Features, along with medical diagnoses of hypertension, chronic obstructive pulmonary disease (COPD), and obesity. She had been admitted to a private hospital twice in the last 2 months. The last admission at the private hospital lasted 18 days and she was described as refusing medication, electively non-verbal and mute. Family members reported that “she refused to participate in any kind of treatment and would not do
12 anything. She would not take any medication but was eating and drinking.” Her husband reported that when she was discharged she took risperidone for 2 days and did very well. “She was talking to everybody and was interacting with the family members, too.” However, she stopped taking her risperidone and he explained that “she has progressed to the point where she is not talking to any family members or anybody else.” After 3 days at home, the family took her to the psychiatric state hospital for admission. On day 1 at the psychiatric state hospital, the initial evaluation reported that “she is not eating and not taking care of herself.” “The patient is electively mute and did not offer any complaint.” “The patient is electively mute and refused to answer any questions.” According to the mental status exam at admission, “She answered 1 or 2 questions with ‘no’ when we asked whether anybody is abusing her, but she did not say anything.” The pharmacological treatment included risperidone 2 mg/day (administered as 1 mg twice a day) “since the family reported that she responded well to the medication” and sertraline 50 mg/day. Benzodiazepines or electroconvulsive therapy were not considered. 2.2.2. Course during Hospitalization that Led to Death On day 2 of admission, the psychiatric evaluation documented, “At that time, she was noted to follow directions without difficulty, including presenting herself to the interview room. She, however, did not offer verbalization during the interview process. She established adequate eye contact. She appeared at times to respond to questions with slight movements of her head.” The patient was described as nonverbal on day 5 and on day 23. On day 23, the nutritionist documented that nutritional intake was adequate. On day 27, a nursing daily note described the patient as “withdrawn from peers and staff. Patient is quiet and calm. Refuse to interact with staff when prompted. Patient paces in hallway, tearful at times. Refuses to attend activities of daily living (ADLs) independently but will with assistance. Selectively mute. Patient is incontinent of urine and stool at times. Patient appears confused and disoriented at times.” On day 29, the patient was informed that her husband had been appointed as her guardian. On the same day 29, an IM injection of lorazepam 2 mg was administered for agitation. Then
13 the treating psychiatrist documented, “It is noted subsequent to this administration over a several-hour period, the patient was able to communicate verbally clearly and concisely.” Three hours later the psychiatrist started clonazepam 1 mg/day (0.5 twice a day). 2.2.3. Death The death occurred on the morning of day 32 of admission. At that time the patient 1) was not independently ambulatory but definitively moving more than in the last 3 months, 2) used a rolling recliner for her pedal edema and 3) needed assistance for her ADLs. In the middle of the morning, the patient complained of not being able to breathe and a dose of albuterol inhaler as needed was given. An as-needed order of albuterol inhaler was started upon admission but had not previously been used. Then the patient was assisted by staff to take a shower in the bathroom. Thirty-three minutes after the inhaler administration, the patient was being rolled out of the bathroom in her rolling recliner. Once the patient was in the hallway, a staff member asked the patient to lift her feet up but the patient did not respond. The staff reported that “her eyes were rolled back into her head and she was foaming at the mouth.” CPR was started. The Automatic Emergency Defibrillator (AED) advised that no electric shock should be administered. The patient was transferred to a medical hospital ER where she was declared dead at 1 hour and 20 minutes after the inhaler administration and 47 minutes after she became unresponsive. The family refused the autopsy. At the time of the death, her medication included sertraline 100 mg/day, risperidone 4 mg/day, and clonazepam 1 mg/day, lisinopril 20 mg/day for hypertension; insulin on a sliding scale for diabetes mellitus, an inhaler with fluticasone and salmeterol (1 puff twice a day) for COPD; fluticasone spray (1 spray per nostril twice a day) for rhinitis; and polyethylene glycol (17 g per day) for constipation. 2.2.4. Retrospective Diagnosis of Catatonia The patient met four of twelve DSM-5 diagnostic criteria for Catatonia including stupor, mutism, negativism, and posturing. Based on the labs and past medical history, there were no medical conditions,
14 such as neurological or metabolic diseases, which could have caused catatonia. Catatonia was probably associated with Major Depressive Disorder. 2.2.5. Treatment with Benzodiazepines and ECT During the 2 months she had catatonia before the last admission, she did not receive benzodiazepines or ECT. During the 32-day period of the last admission, she received only 2 mg IM of lorazepam for agitation on day 29, which unexpectedly led to a decrease in catatonic symptoms. Then clonazepam 1 mg/day was started and the patient received a total of 3 mg prior to her death. With the benzodiazepine treatment, the patient did not become independent in ambulation but appeared to move more. It cannot be ruled out that the partial response of increased mobility may have contributed to PE after 3 months of immobility. 2.2.6. Retrospective Diagnosis of PE Based on Malý et al. (49), this patient had four risk factors for VTE including immobilization, dehydration, obesity, and treatment with antipsychotics which present a medium risk. The suspected cause of death was PE, taking into consideration listed VTE risk factors and presentation of acute dyspnea of no other known etiology leading to a prompt death. 2.3. Case 3 2.3.1. Prior History The patient was a 57-year-old Caucasian female with a previous diagnosis of Recurrent Major Depression and several psychiatric hospitalizations. Her psychiatric history is remarkable for an extensive history of symptoms of depression, anxiety, catatonia, and psychosis, requiring multiple treatment interventions over 35 years including clozapine and multiple treatments with ECT. Her medical diagnoses were hypothyroidism, GERD, diabetes mellitus, vitamin D deficiency, and obesity. In the prior month, she was admitted to an academic hospital and left against medical advice three weeks before the psychiatric admission to the state hospital. It appears that after leaving against medical advice she was admitted to one medical community hospital. At that hospital an NG tube was placed to feed her. Then
15 she was transferred to a second medical community hospital from which the patient was transferred to the state hospital with an involuntary court order. In summary, the patient had been catatonic for several weeks, possibly up to 2 months, with sufficient impairment to require an NG tube placement because she was not eating and drinking. 2.3.2. Course during Hospitalization that Led to Death On the day of admission (day 1), the patient was described as non-cooperative, guarded, and mute with an apparent depressed mood with constricted range. The mental status exam was remarkable for psychomotor retardation, posturing, and poor eye contact. Her prior psychiatric home medications were haloperidol, 10 mg/day (5 mg twice a day), benztropine, 1 mg/day (0.5 twice a day) and venlafaxine, 150 mg/day (75 mg twice a day). They were continued in the psychiatric state hospital and administered using the NG tube. The admitting psychiatrist ordered 1 mg of clonazepam every 6 hours as needed for anxiety or agitation which was never used during the admission. Her medical medications at admission were levothyroxine 112 μg/day and pantoprazole 40 mg/day which was changed to omeprazole 20 mg/day. Laboratory results were significant for hyperglycemia and hypokalemia 3.1 mmol/L (normal range 3.55.1). Potassium chloride 20 mEq per day was added. Thyroid function tests and Hemoglobin A1C were within normal limits. Urine was negative for acetone, infection signs and drug screen. On day 4 of admission, her catatonia was characterized by mutism and a non-cooperative, blank facial expression. She had also been incontinent and confined to a chair; her self-care was described as poor. The ancillary tests demonstrated an elevated BUN of 28 mg/dL (normal range 6-21) and normal liver enzymes; the EKG showed sinus bradycardia with questionable/possible left ventricle hypertrophy and nonspecific T abnormalities. The haloperidol 10 mg/day was changed to lurasidone 80 mg/day (so the psychiatric treatment at that time included lurasidone 80 mg/day, benztropine 1 mg/day and venlafaxine 150 mg/day). On day 5, a physical exam demonstrated regular heart rate and rhythm. Lipid profile was normal except for total cholesterol of 217 mg/dL (optimal
