The Voice of Science to Houston Control

Is Shooting Patients with Catatonia the Best Way to Manage Them?

Posted Nov 21, 2015

On August 27, 2015, an off-duty police officer, moonlighting as security at the St Joseph Medical Center in Houston, shot Alan Pean, a 26-year-old man with a history of manic depressive and anxiety symptoms.

Pean was in the middle of an episode of delirious mania, filled with manic violence and lacking any awareness of where he was or ability to appreciate the current situation.  Delirious mania is a form of catatonia, and has been recognized as a kind of classic “mania” (in the sense of violent outbursts, not a euphoric mood disorder) for over a century.  (See Max Fink and MA Taylor, Catatonia: A Clinician’s Guide to Diagnosis and Treatment, Cambridge UP, 2003)

Pean had refused to stay in his room, removed all his clothes, rushed out into the corridor naked, was screaming and yelling incomprehensibly. So far, this is a normal case of delirious mania.

What was not normal was that in Houston, hospital security carried guns. The off-duty officer confronted Pean (another cop apparently joined the scene as well). Pean refused to calm down (he was in the middle of an episode of delirium!); he threw a hospital tray table at the officer.

And the officer responded in the only way the Houston police know how when someone throws a tray table at them in a psychiatric ward: The officer shot Pean in the chest (Pean survived, barely).

The hospital administration, of course, immediately took the side of the cops. Hospital CEO Mark Bernard said it was perfectly appropriate for the off-duty officer to enter “police mode” when someone throws a tray table at him. “If it should happen today, they would not have done anything different,” said Bernard. “The patient’s aggression towards the officers was a criminal offense.”

This is rich. A psychiatric patient who throws a tray table has committed a criminal offense and may be the object of “lethal force.” Any concept that the symptoms of psychiatric patients may involve aggression and agitation – and should be the object of medical not police attention -- has been lost here.

I have a couple of questions, given that the federal Centers for Medicare and Medicaid Services are withdrawing the hospital’s funding:

1. Does CEO Bernard’s Plan B involve accepting future employment at a post where he must practice the phrase, “Would you like fries with that?”

2. Where was the medical leadership when all this was happening? Agitated patients screaming and yelling in the corridors and no physician in sight to correctly assess the situation and implement proper treatment? Delirious mania, as a form of catatonia, responds readily to benzodiazepines (such as Valium). Rather than shooting Pean, hospital workers – or the two cops --  could have restrained him long enough to pump 20 cc of Valium into him, and then another 20 if he failed to calm. Was there no physician in evidence on the obviously incompetently managed ward who could have given the necessary order?

3. Are psychiatrists at St. Joseph’s even aware that there is such a diagnosis as manic delirium? After all, they had previously diagnosed Pean with “depression” and “anxiety,” common enough conditions but also possibly in this case, “wastebasket diagnoses”: A diagnosis you use faute de mieux, lacking anything better, and because, in the last analysis, you really can't be bothered. Pean was, they may have thought, an obvious nut job but to get reimbursement we’ve got to diagnose him as something.

Every police department in the world is amply familiar with delirious mania, patients who seem simply to run amok, take off all their clothes, bellow incomprehensibly, and are actually at great risk of attacking others. Most cops don’t have a clue, and shoot someone whose behavior seems so bizarre and threatening.

But this cop was in the middle of a psychiatry department! Inconceivable.

Delirious mania isn’t in the DSM, the “bible” of psychiatry. But then a lot of other conditions that really exist, such as melancholia, aren’t in the DSM either (in any but a token way). The Houston psychiatrists may have tunnel vision, unaware of anything not in the DSM.

But, hey, we’re dealing with people’s lives here. Alan Pean almost lost his because of inappropriateness, incompetence, and ignorance. The Voice of Science to Houston Control:  “Surely you guys can do better than this?”