How Everyone Became Depressed

The rise and fall of the nervous breakdown

A Great Season for Catatonia!

Request for drug use patent for catatonia speaks volumes.

This has been a great season for catatonia! First, the clunky DSM-5 made it an official independent diagnosis in May, detaching it from schizophrenia as a “subtype.” This means that clinicians can now diagnose catatonia plus whatever it’s attached to, like depression, when they encounter it.

Then one of the lead psychiatry journals, Acta Psychiatrica Scandinavica, just published as a “supplement” a small book by Max Fink giving a run down on catatonia, how to diagnose it and treat it.

And just yesterday, look what crossed my desk! Corcept Therapeutics in California wants a use patent for their drug mifepristone in the treatment of catatonic agitation alternating with stupor. It’s been a long time since anyone tried to patent anything in the catatonia area, and that this little company – which for years has been seeking uses for its drug mifepristone – is now going after catatonia speaks volumes. We’re on the verge on a catatonia revival.

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For those of you who came in late, catatonia is a “motor” (movement) disorder in connection with other psychiatric syndromes that may involve blank staring off into space for hours on end (and, no, my students do not have catatonia); suddenly the patients might come out of this stupor to leap wildly about the room (agitation). Or they might have ceaselessly repetitive muscle movements, as in the stereotypical tics and flailings of children with autism and intellectual disability; or they might be mute, or generally negativistic, or strike postures and hold them for hours on end. There are lots of different forms of catatonia. It’s actually quite common in psychiatry, and for this now to be a commercial target is really very interesting.

(On a pedantic note, contrary to the patent claim, excited catatonia is not the same thing as the lethal version, where the patients may not have manic delirium at all.)

Now, I know what you’re going to say. “Listen, Edward, we’ve already got two perfectly effective treatments for catatonia – the drug lorazepam and electroconvulsive therapy. Why do we need this?”

And you’d be right. But the comment shows that you don’t understand how pharmaceutical marketing works. It’s by badmouthing the competition.

Both ECT and lorazepam are highly safe and effective in treating catatonia. There’s not a lot of runway left. So, what to do?

We hear the solution already in the language of the patent claim: ECT is “controversial,” med-speak for doctor stay away from it; and the benzodiazepines “can be addicting,” and, doctor, you really aren’t thinking about prescribing them when you have safe alternative X at hand. (This is the tactic that was used to market the Prozac-style drugs: They were hyped as a non-addictive alternative to the dangerous benzodiazepine drug class!)

Both claim are urban myths. There is nothing controversial in psychiatry about ECT: Every major psychiatric organization in the world has endorsed it. It has relatively few side effects and has saved many lives. And the benzos, as a drug class, don’t deserve the addictiveness label that has been pinned on them: in medicine, one always balances the expected benefits against the relative risks, and with lorazepam and its cousins the benefits in the treatment of anxiety, mild depression, catatonia, insomnia, and so forth are very considerable.

But that’s reality, and past experience has shown that in the world of pharmaceutical advertising, reality doesn’t matter. You can always find something in “the literature” to get the Food and Drug Administration to accept your slagging of the competition, and physicians are often goggle-eyed with acceptance of the claims of the masculine young drug reps and their gorgeous female colleagues.

I’m not saying the mifepristone gang will go this route. After they win a patent, the next thing they have to do is to get this indication through FDA. (Mifepristone is already on the market as Korlym for the treatment of patients with Cushing’s syndrome.) But for catatonia buffs, hey! It’s been a good month. 

Edward Shorter, Ph.D., is the Jason A. Hannah Professor in the History of Medicine at the University of Toronto.

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