Combination of Electroconvulsive Therapy and Clozapine in the Treatment of Malignant Catatonia: A Case Report

Abstract A woman with treatment-resistant mania and malignant catatonia failed to respond to several of the conventional treatments including electroconvulsive therapy but showed a marked response to a combination of clozapine (250 mg daily) and electroconvulsive therapy within a few days of initiating treatment. Key words: Antidepressive agents, tricyclic; Catatonia; Combined modality therapy; Electroconvulsive therapy; Schizophrenia [TEXT NOT REPRODUCIBLE IN ASCII] Introduction Catatonia is a syndrome characterised by motor signs such as posturing, catalepsy, waxy flexibility, and rigidity. Behaviour may change suddenly, ranging between extremes of excitement and stupor, and may include staring, negativism, impulsivity, mannerisms, stereotypy, echolalia, echopraxia, and automatisms. (1,2) The severity of catatonia ranges from mild to lethal. Stauder first applied the term 'lethal catatonia' in 1934 to describe a life-threatening syndrome characterised by mounting fever, intense excitement, diverse catatonic presentations, followed by stupor and death. At the 1992 American Psychiatric Association meeting, a new term, 'malignant catatonia', was suggested as a replacement for lethal catatonia, based on the perception of decreasing mortality in this condition. (3) Several authors have suggested use of the term 'simple or non-malignant catatonia' in the absence of autonomic instability or hyperthermia and 'malignant catatonia' when these symptoms are present. (1,2) Neuroleptic malignant syndrome was first reported in the 1960s as a rare but potentially lethal complication of antipsychotic medication use. (4) Neuroleptic malignant syndrome is clinically indistinguishable from malignant catatonia in many cases and it is speculated by many authors that it is an iatrogenic form of malignant catatonia. (5) As a result, the term 'neuroleptic-induced catatonia' is also used to describe the condition. (1-3) Many investigators believe that catatonia is best understood as a final pathway for many central nervous system disorders and the only important difference is whether the syndrome arose spontaneously or whether it was triggered or accelerated by neuroleptic exposure. (4,6) Various pharmacological and non-pharmacological methods of treatment have been described in the literature. Ungvari et al (7) reviewed the pharmacological treatment of catatonia and concluded that benzodiazepines are an effective treatment for most of the symptoms and signs of catatonia. Patients who do not respond to benzodiazepines are treated with electroconvulsive therapy (ECT). (2) In malignant catatonia, emergency ECT is the treatment of choice. General supportive measures such as maintaining fluid balance and nutrition are important. Although antipsychotics are generally not recommended during a catatonic phase, as the risk of precipitating neuroleptic malignant syndrome is considerably increased, they may have a role in treatment-resistant cases. (2) Case reports have described the effectiveness of clozapine, risperidone, and a combination of olanzapine and ECT. (8-10) We report a case of a woman in her fifties with treatment-resistant mania and malignant catatonia who failed to respond to several of the well-known treatments but showed a marked response and made a full recovery after treatment with a combination of ECT and clozapine. Case Report Mrs B was a 50-year-old caucasian, married and employed lady. Her son was diagnosed as having bipolar affective disorder and a learning disability. She had worked as a nurse for more than 10 years, and as a nursing manager for about 6 months, prior to the episode we describe. She had a history of alcohol misuse extending back for the last 30 years. She was admitted in July 2006 to an acute adult psychiatric unit after a mental health assessment initiated by the police. Two months prior to the psychiatric unit admission, she had been on holiday and had no symptoms suggestive of affective disorder at that time. …