To the Editor: In 1880 the French psychiatrist Jules Cotard described several patients who suffered from a syndrome referred to as délire de négation (1). This relatively rare syndrome is characterized by the presence of nihilistic delusions that one is dead or the world no longer exists (2). I report a case of a man who developed Cotard's syndrome while living in an urban shelter for the homeless. What makes this case noteworthy, apart from the rarity of the clinical syndrome, is the protracted morbidity and suffering endured by an impoverished individual because he was unable to pay for psychiatric services.
Mr. K, a 44-year-old Caucasian man, had recently relocated from New York to Florida. He was unable to find employment and became homeless. While he was in jail on a trespassing charge, he developed signs of depression that was not identified or treated. After he returned to the homeless center where he was residing, his depressive symptoms worsened over a six-week period. He reported to his case manager feelings of hopelessness, poor sleep, decreased appetite, and anergia. Because he had not yet applied for public health insurance and had no means of paying, he was not seen by a psychiatrist until he was taken to the public crisis unit several weeks later after stating that he had "melted away" and was "dead."
At the crisis unit Mr. K was diagnosed as having schizophrenia, treated with a combination of oral and depot haloperidol, and discharged back to the homeless center. Because he lacked insurance, the community mental health center referred him to the homeless center's primary care clinic for follow-up. Over the course of several weeks his symptoms and daily functioning worsened. He continued to voice delusional beliefs, such as "my brain's rotted away," "parts of my insides are gone," and "I'm dead." He denied perceptual abnormalities and suicidal ideation. He was readmitted to the crisis unit, where valproic acid and fluoxetine were added to his regimen of haloperidol. He was discharged several days later with little improvement in his symptoms.
Mr. K was then referred to a university-affiliated free psychiatric clinic that had recently been established at the homeless center. A diagnosis of major depression with psychotic features consistent with Cotard's syndrome was made. Because of the duration of his illness—four months—and its associated morbidity, the clinic staff decided to hospitalize him and to administer electroconvulsive therapy (ECT), which has been shown to be efficacious in the treatment of Cotard's syndrome (3,4). The university-affiliated hospital did not offer ECT, and the clinic staff personally requested that administrators and treating physicians at the few area hospitals providing ECT accept Mr. K for treatment. In all cases he was denied admission because of his lack of insurance and inability to pay for services.
The university-affiliated hospital agreed to admit Mr. K on a "compassionate" basis. Over the course of several days his dosages of haloperidol and valproic acid were tapered. Fluoxetine was increased to 40 mg a day, and risperidone was initiated and titrated to 3 mg a day. Mr. K made slow progress over the next two weeks. His nihilistic delusions diminished, and he experienced partial resolution of major depressive symptoms. In the several months since he was discharged, he has continued to improve and has had no recurrence of the nihilistic delusions or of major depression.
I present this case not only to illustrate the unique constellation of symptoms associated with Cotard's syndrome but also to underscore the persistent obstacles to care often encountered by the poorest and most ill members of our communities. It remains a human and social tragedy in our country that the ability to pay rather than medical need is what determines whether a person receives timely and appropriate psychiatric services.
Dr. Christensen is assistant clinical professor and director of the community psychiatry program at the University of Florida College of Medicine in Jacksonville.