CASE VIGNETTE
“Mrs Brick” is a 56-year-old Caucasian feminine with a historical past of continual schizophrenia. She had been steady on a medicine routine of risperidone 4 mg at bedtime and citalopram 20 mg within the morning. Within the earlier 6 months, nevertheless, she had misplaced her mom to heart problems and her brother, who died inside 2 months of a most cancers prognosis. Mrs Brick’s husband took her to the emergency division due to deficits in self-care. Mrs Brick had not been consuming nicely and had misplaced 15 kilos in 2 months. She had low vitality and poor focus. She had been isolating in mattress more often than not and he or she required vital prompting to attend to non-public hygiene. On examination, it was found that she had profound psychomotor retardation, poverty of speech, and elevated latency of response. She additionally exhibited some gentle posturing.
Mrs Brick was admitted to the inpatient psychiatric unit. Laboratory research had been unremarkable. She was began on lorazepam 1 mg 3 occasions every day for catatonia and her risperidone was elevated to six mg. After 3 days, her situation remained largely unchanged. Subsequently, her psychiatrist began her on clozapine, which was titrated over the following week to a dose of 200 mg at bedtime. This was related to enchancment in signs of catatonia. Mrs Brick was capable of articulate feeling depressed about her current losses in addition to suspiciousness that somebody in her neighborhood was plotting to kill her. Her temper and paranoia additionally improved with clozapine. She was discharged dwelling on hospital day 14 within the care of her husband.
Catatonia is a bunch of signs characterised by abnormalities in motion, speech, and habits. Prevalence is 9% in acute psychiatric affected person populations.1 Catatonia was classically tied to schizophrenia however it’s related to different psychiatric and medical issues. First-line therapy for catatonia, past addressing underlying causes and issues, is benzodiazepines.2 Electroconvulsive remedy (ECT) additionally performs an essential function within the therapy of catatonia, significantly whether it is proof against benzodiazepines or in emergencies.3 Different medicines, together with atypical antipsychotics, have been used off label for treatment-resistant catatonia.
The atypical antipsychotic clozapine, with its distinctive pharmacologic profile, together with comparatively weaker dopamine D2 receptor antagonism, represents a possible therapy for each catatonia and underlying psychosis. There’s additionally proof for catatonia following clozapine withdrawal.4 Nevertheless, proof for clozapine as a possible therapy for catatonia has not been systematically reviewed.
The Present Research
Saini and colleagues carried out a scientific overview of clozapine within the therapy of catatonia.5 The authors used the NICE Healthcare databases to look Medline, EMBASE, PubMed, PsycINFO, and CINAHL from inception by means of June 2021. They included English-language, unique, full-text research in peer-reviewed journals; the checked out all research designs with no less than 1 affected person with catatonia handled with clozapine, though case studies and case collection had been grouped individually. Research had been excluded if catatonia was not recognized by a clinician or catatonia occurring within the context of neuroleptic malignant syndrome, or the place upkeep clozapine was used just for secondary prophylaxis of catatonia. Information on demographic and scientific traits had been collected for every research. Quantitative overview (ie, meta-analysis) was not doable, as most research had been case studies or case collection. The authors assessed the methodological high quality of the case studies and case collection utilizing a printed device.6
The authors recognized 849 research from preliminary searches, of which 93 had been included. This consisted of 79 case studies, 8 case collection, and 6 cohort research. The ultimate pattern handled with clozapine consisted of 182 sufferers, together with 101 from case studies or case collection and 81 from cohort research. Within the cohort research, the one specified prognosis was schizophrenia, which was current in no less than 68% of sufferers. The result was reported as full remission in 10%, partial remission in 74%, and no change in 7%. Reporting of hostile results was restricted. Different scientific knowledge had been restricted throughout the cohort research.
Within the case studies and case collection, the imply age was 35 years (however the age vary was broad), 65% had been male, and 63% had schizophrenia or associated psychosis. Benzodiazepines, different antipsychotics, and ECT had been generally used. Full remission occurred in 63%, partial remission in 18%, and no change in 19%, after a imply of 54, 72, and 41 days between clozapine initiation and end result evaluation. A minority of catatonia diagnoses (24%) had been reported to comply with clozapine withdrawal. The vast majority of included research had been deemed to be of reasonable high quality.
Research Conclusions
Full or partial remission charges had been 84% in cohort research and 81% in case studies or case collection, with therapy over a interval of weeks to months. The imply peak dose of clozapine was 322 mg. A serious limitation is the absence of any managed therapy trials, which precluded the usage of meta-analysis. Additionally, knowledge on blood clozapine ranges weren’t out there for almost all of sufferers. There could have been potential confounding by different psychotropic medicines. The principle research energy is that it’s the first systematic overview of clozapine for the therapy of catatonia.
The Backside Line
There’s very modest proof that clozapine could also be related to enchancment of catatonia. Clozapine represents a possible second-line therapy for catatonia following failure of benzodiazepines or ECT or if precipitated by clozapine withdrawal. Future analysis ought to use giant well being care databases to evaluate whether or not clozapine is related to higher outcomes in catatonia. Additional assist may justify a scientific trial on this space.
Dr Miller is a professor within the Division of Psychiatry and Well being Conduct at Augusta College in Augusta, Georgia. He’s on the editorial board and serves because the schizophrenia part chief for Psychiatric Instances™. The creator studies that he receives analysis assist from Augusta College, the Nationwide Institute of Psychological Well being, and the Stanley Medical Analysis Institute.
References
1. Sienaert P, Dhossche DM, Vancampfort D, et al. A scientific overview of the therapy of catatonia. Entrance Psychiatry. 2014;5:181.
2. Solmi M, Pigato GG, Roiter B, et al. Prevalence of catatonia and its moderators in scientific samples: outcomes from a meta-analysis and meta-regression evaluation. Schizophr Bull. 2018;44(5):1133-1150.
3. Steering on the usage of electroconvulsive remedy. Nationwide Institute for Well being and Care Excellence. April 26, 2003. Accessed December 13, 2022. https://www.good.org.uk/steering/ta59
4. Lander M, Bastiampillai T, Sareen J. Evaluation of withdrawal catatonia: what does this reveal about clozapine? Transl Psychiatry. 2018;8(1):139.
5. Saini A, Begum N, Matti J, et al. Clozapine as a therapy for catatonia: a scientific overview. Schizophr Res. 2022;S0920-9964(22)00363-2.
6. Murad MH, Sultan S, Haffar S, Bazerbachi F. Methodological high quality and synthesis of case collection and case studies. BMJ Evid Primarily based Med. 2018;23(2):60-63.
