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Dell’Osso L, Bonelli C, Nardi B, Giovannoni F, Pronestì C, Cremone IM, Amatori G, Pini S, Carpita B. Rethinking Clozapine: Lights and Shadows of a Revolutionary Drug. Brain Sci 2024; 14:103. [PMID: 38275523 PMCID: PMC10813979 DOI: 10.3390/brainsci14010103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 01/16/2024] [Accepted: 01/18/2024] [Indexed: 01/27/2024] Open
Abstract
The current literature globally highlights the efficacy of Clozapine in several psychiatric disorders all over the world, with an FDA indication for reducing the risk of repeated suicidal behavior in patients with schizophrenia or schizoaffective disorder. A growing field of research is also stressing a possible broader beneficial effect of Clozapine in promoting neuroprotection and neurotrophism. However, this drug is linked to several life-threatening side effects, such as agranulocytosis, myocarditis and seizures, that limit its use in daily clinical practice. For this work, a search was performed on PubMed using the terms "Clozapine indications", "Clozapine adverse effects", "Clozapine regenerative effects", and "Clozapine neuroplasticity" with the aim of reviewing the scientific literature on Clozapine's treatment indications, adverse effects and potential regenerative role. The results confirmed the efficacy of clozapine in clinical practice, although limited by its adverse effects. It appears crucial to raise awareness among clinicians about the potential benefits of using Clozapine, as well educating medical personnel about its risks and the early identification of possible adverse effects and their management.
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Affiliation(s)
| | - Chiara Bonelli
- Department of Clinical and Experimental Medicine, Section of Psychiatry, University of Pisa, 67 Via Roma, 56126 Pisa, Italy; (L.D.); (B.N.); (F.G.); (C.P.); (I.M.C.); (G.A.); (S.P.); (B.C.)
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Fritze S, Brandt GA, Kubera KM, Schmitgen MM, Northoff G, Geiger-Primo LS, Tost H, Meyer-Lindenberg A, Wolf RC, Hirjak D. Structural alterations of amygdala and hypothalamus contribute to catatonia. Schizophr Res 2024; 263:122-130. [PMID: 35597738 DOI: 10.1016/j.schres.2022.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/03/2022] [Accepted: 05/04/2022] [Indexed: 12/12/2022]
Abstract
At present, current diagnostic criteria and systems neglect affective symptom expression in catatonia. This potentially serious omission could explain why putative contributions of limbic system structures, such as amygdala, hippocampus or hypothalamus, to catatonia in schizophrenia spectrum disorders (SSD) have been scarcely investigated so far. To determine whether topographical alterations of the amygdala, hippocampus and hypothalamus contribute to catatonia in SSD patients, we conducted structural magnetic resonance imaging (MRI) of SSD patients with (SSD-Cat, n = 30) and without (SSD-nonCat, n = 28) catatonia as defined by a Northoff Catatonia Rating Scale (NCRS) total score of ≥3 and =0, respectively, in comparison with healthy controls (n = 20). FreeSurfer v7.2 was used for automated segmentation of the amygdala and its 9 nuclei, hippocampus and its 21 subfields and hypothalamus and its associated 5 subunits. SSD-Cat had significantly smaller anterior inferior hypothalamus, cortical nucleus of amygdala, and hippocampal fimbria volumes when compared to SSD-nonCat. SSD-Cat had significantly smaller amygdala, hippocampus and hypothalamus whole and subunit volumes when compared to healthy controls. In SSD-Cat according to DSM-IV-TR (n = 44), we identified positive correlations between Brief Psychiatric Rating Scale (BPRS) item #2 (reflecting anxiety) and respective amygdala nuclei as well as negative correlation between NCRS behavioral score and hippocampus subiculum head. The lower volumes of respective limbic structures involved in affect regulation may point towards central affective pathomechanisms in catatonia.
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Affiliation(s)
- Stefan Fritze
- Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Geva A Brandt
- Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Katharina M Kubera
- Center for Psychosocial Medicine, Department of General Psychiatry, Heidelberg University, Heidelberg, Germany
| | - Mike M Schmitgen
- Center for Psychosocial Medicine, Department of General Psychiatry, Heidelberg University, Heidelberg, Germany
| | - Georg Northoff
- Mind, Brain Imaging and Neuroethics Research Unit, The Royal's Institute of Mental Health Research, University of Ottawa, Ottawa, ON, Canada
| | - Lena S Geiger-Primo
- Department of Psychiatry and Psychotherapy, Research Group System Neuroscience in Psychiatry, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Germany
| | - Heike Tost
- Department of Psychiatry and Psychotherapy, Research Group System Neuroscience in Psychiatry, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Germany
| | - Andreas Meyer-Lindenberg
- Department of Psychiatry and Psychotherapy, Research Group System Neuroscience in Psychiatry, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Germany
| | - Robert C Wolf
- Center for Psychosocial Medicine, Department of General Psychiatry, Heidelberg University, Heidelberg, Germany
| | - Dusan Hirjak
- Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany.
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Caroff SN, Ungvari GS, Gazdag G. Treatment of schizophrenia with catatonic symptoms: A narrative review. Schizophr Res 2024; 263:265-274. [PMID: 36404216 DOI: 10.1016/j.schres.2022.11.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 11/07/2022] [Accepted: 11/09/2022] [Indexed: 11/19/2022]
Abstract
Catatonia is a neuropsychiatric syndrome consisting of psychomotor abnormalities caused by a broad range of disorders affecting brain function. While the nosological status of catatonia is no longer restricted to a subtype of schizophrenia in standardized diagnostic systems, the character, course, and clinical significance of catatonia in people with schizophrenia remain unclear. Evidence suggests that catatonia could be a nonspecific state-related phenomenon, a fundamental core symptom dimension of schizophrenia, or a subcortical variant of schizophrenia. Either way, the validity of catatonia in schizophrenia is clinically significant only insofar as it predicts prognosis and response to treatment. Most contemporary clinical trials of antipsychotics have targeted schizophrenia as an overly broad unitary psychosis neglecting any differential response defined by phenomenology or course. However, early naturalistic studies showed that catatonia predicted poor response to first-generation antipsychotics in chronic schizophrenia and case reports cautioned against the risk of triggering neuroleptic malignant syndrome. More recent studies suggest that second-generation antipsychotics, particularly clozapine, may be effective in schizophrenia with catatonic symptoms, while small randomized controlled trials have found that the short-term response to ECT may be faster and more significant. Based on available data, conclusions are limited as to whether antipsychotics are as effective and safe in acute and chronic schizophrenia with catatonic symptoms compared to other treatments and compared to schizophrenia without catatonia. Further studies of the pathophysiology, phenomenology, course and predictive value of catatonia in schizophrenia are worthwhile.
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Affiliation(s)
- Stanley N Caroff
- Behavioral Health Service, Corporal Michael J. Crescenz VA Medical Center and the Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Gabor S Ungvari
- Division of Psychiatry, School of Medicine, University of Western Australia, Crawley, Australia; Section of Psychiatry, University of Notre Dame, Fremantle, Australia
| | - Gábor Gazdag
- Department of Psychiatry and Psychiatric Rehabilitation, Jahn Ferenc South Pest Hospital, Budapest, Hungary; Department of Psychiatry and Psychotherapy, Faculty of Medicine, Semmelweis University, Budapest, Hungary
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Grover S, Kathiravan S. Clozapine research from India: A systematic review. Asian J Psychiatr 2023; 79:103353. [PMID: 36493690 DOI: 10.1016/j.ajp.2022.103353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 11/09/2022] [Accepted: 11/20/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Although clozapine is much researched in western literature, a review on Indian research on clozapine published in 2010 reported limited data and need for further research in this area. AIM We aimed to conduct a systematic review of research on clozapine from India from 2010 to mid-2022 and also compare the same with research output before 2010. METHODOLOGY A systematic various search engines, i.e., PUBMED, Medknow, Hinari and Google Scholar was done using the key words clozapine and India. Published articles with clozapine in the title and having an author from India, published during 2010 to July 2022 were included. RESULTS Initial Internet and hand searches yielded 280 articles, out of which 126 articles were excluded due to various reasons and 154 articles, were included for the review. This included 84 case reports, 49 original articles, 11 review articles and 10 letters to the editor as comments. We found an increase in the number of publications during the period of 2010-2022 compared to 1997-2009 in all types of publications. Over the years a significant proportion of the articles focused on various side effects of clozapine, factors associated with response and non-response to clozapine and evaluation of outcomes other than efficacy/effectiveness. However, all the studies were limited to a single centre with no multicentric studies on clozapine. CONCLUSION Over the last 12 years or so, there is increase in the number of publications on clozapine. However, there is lack of multicentric studies.
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Affiliation(s)
- Sandeep Grover
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India.
| | - Sanjana Kathiravan
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
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ECT-resistant Catatonia: Case Report and Literature Review. J Acad Consult Liaison Psychiatry 2022; 63:607-618. [PMID: 35842127 DOI: 10.1016/j.jaclp.2022.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 06/30/2022] [Accepted: 07/07/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Untreated catatonia is associated with serious medical complications that can necessitate urgent medical attention1,2. Lorazepam and electroconvulsive therapy (ECT) are effective for catatonia across various psychiatric or medical diagnoses1,3. In rare cases, ECT fails to achieve full response in catatonic symptoms, particularly in patients with chronic catatonia or primary psychotic disorder4,5. Evidence on treating catatonia that does not respond to ECT is lacking. OBJECTIVES Conduct a literature review on treatment of ECT-resistant catatonia which is defined as reported lack of full response to ECT treatments. We present a case of a 52-year-old male with schizophrenia where catatonia did not respond to lorazepam and robust ECT but resolved after memantine titration. METHODS A literature review was performed using Medline/PubMed with the following keywords: treatment-resistant, catatonia, electroconvulsive therapy. References in eligible articles and most recent systematic reviews on catatonia treatment were reviewed. RESULTS Seventeen patients in twelve case reports were identified where the treatment of catatonia was described after failed ECT trials. Most had chronic catatonia and a diagnosis of schizophrenia. ECT parameters and ictal outcome measures were not consistently reported. Treatment modalities for ECT-resistant catatonia included amantadine, memantine, lorazepam augmentation to ECT, antiepileptic and antipsychotic medications such as aripiprazole and clozapine. CONCLUSIONS The literature review and new case suggest reconsideration of catatonia diagnosis, optimizing ECT treatments, cautious use of antipsychotics, consideration of lorazepam augmentation to ECT treatments and/or use of N-methyl-D-aspartate (NMDA) receptor antagonists.
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Huang MW, Gibson RC, Jayaram MB, Caroff SN. Antipsychotics for schizophrenia spectrum disorders with catatonic symptoms. Cochrane Database Syst Rev 2022; 7:CD013100. [PMID: 35844143 PMCID: PMC9289703 DOI: 10.1002/14651858.cd013100.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Whilst antipsychotics are the mainstay of treatment for schizophrenia spectrum disorders, there have been numerous attempts to identify biomarkers that can predict treatment response. One potential marker may be psychomotor abnormalities, including catatonic symptoms. Early studies suggested that catatonic symptoms predict poor treatment response, whilst anecdotal reports of rare adverse events have been invoked against antipsychotics. The efficacy and safety of antipsychotics in the treatment of this subtype of schizophrenia have rarely been studied in randomised controlled trials (RCTs). OBJECTIVES To compare the effects of any single antipsychotic medication with another antipsychotic or with other pharmacological agents, electroconvulsive therapy (ECT), other non-pharmacological neuromodulation therapies (e.g. transcranial magnetic stimulation), or placebo for treating positive, negative, and catatonic symptoms in people who have schizophrenia spectrum disorders with catatonic symptoms. SEARCH METHODS We searched the Cochrane Schizophrenia Group's Study-Based Register of Trials, which is based on CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, PubMed, ClinicalTrials.gov, the ISRCTN registry, and WHO ICTRP, on 19 September 2021. There were no language, date, document type, or publication status limitations for inclusion of records in the register. We also manually searched reference lists from the included studies, and contacted study authors when relevant. SELECTION CRITERIA All RCTs comparing any single antipsychotic medication with another antipsychotic or with other pharmacological agents, ECT, other non-pharmacological neuromodulation therapies, or placebo for people who have schizophrenia spectrum disorders with catatonic symptoms. DATA COLLECTION AND ANALYSIS two review authors independently inspected citations, selected studies, extracted data, and appraised study quality. For binary outcomes, we planned to calculate risk ratios and their 95% confidence intervals (CI) on an intention-to-treat basis. For continuous outcomes, we planned to calculate mean differences between groups and their 95% CI. We assessed risk of bias for the included studies, and created a summary of findings table; however, we did not assess the certainty of the evidence using the GRADE approach because there was no quantitative evidence in the included study. MAIN RESULTS Out of 53 identified reports, one RCT including 14 hospitalised adults with schizophrenia and catatonic symptoms met the inclusion criteria of the review. The study, which was conducted in India and lasted only three weeks, compared risperidone with ECT in people who did not respond to an initial lorazepam trial. There were no usable data reported on the primary efficacy outcomes of clinically important changes in positive, negative, or catatonic symptoms. Whilst both study groups improved in catatonia scores on the Bush-Francis Catatonia Rating Scale (BFCRS), the ECT group showed significantly greater improvement at week 3 endpoint (mean +/- estimated standard deviation; 0.68 +/- 4.58; N = 8) than the risperidone group (6.04 +/- 4.58; N = 6; P = 0.035 of a two-way analysis of variance (ANOVA) for repeated measures originally conducted in the trial). Similarly, both groups improved on the Positive and Negative Syndrome Scale (PANSS) scores by week 3, but ECT showed significantly greater improvement in positive symptoms scores compared with risperidone (P = 0.04). However, data on BFCRS scores in the ECT group appeared to be skewed, and mean PANSS scores were not reported, thereby precluding further analyses of both BFCRS and PANSS data according to the protocol. Although no cases of neuroleptic malignant syndrome were reported, extrapyramidal symptoms as a primary safety outcome were reported in three cases in the risperidone group. Conversely, headache (N = 6), memory loss (N = 4), and a prolonged seizure were reported in people receiving ECT. These adverse effects, which were assessed as specific for antipsychotics and ECT, respectively, were the only adverse effects reported in the study. However, the exact number of participants with adverse events was not clearly reported in both groups, precluding further analysis. Our results were based only on a single study with a very small sample size, short duration of treatment, unclear or high risk of bias due to unclear randomisation methods, possible imbalance in baseline characteristics, skewed data, and selective reporting. Data on outcomes of general functioning, global state, quality of life, and service use, as well as data on specific phenomenology and duration of catatonic symptoms, were not reported. AUTHORS' CONCLUSIONS We found only one small, short-term trial suggesting that risperidone may improve catatonic and positive symptoms scale scores amongst people with schizophrenia spectrum disorders and catatonic symptoms, but that ECT may result in greater improvement in the first three weeks of treatment. Due to small sample size, methodological shortcomings and brief duration of the study, as well as risk of bias, the evidence from this review is of very low quality. We are uncertain if these are true effects, limiting any conclusions that can be drawn from the evidence. No cases of neuroleptic malignant syndrome were reported, but we cannot rule out the risk of this or other rare adverse events in larger population samples. High-quality trials continue to be necessary to differentiate treatments for people with symptoms of catatonia in schizophrenia spectrum disorders. The lack of consensus on the psychopathology of catatonia remains a barrier to defining treatments for people with schizophrenia. Better understanding of the efficacy and safety of antipsychotics may clarify treatment for this unique subtype of schizophrenia.
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Affiliation(s)
- Michael W Huang
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Roger Carl Gibson
- Department of Community Health & Psychiatry, University of the West Indies, Mona, Jamaica
| | - Mahesh B Jayaram
- Department of Psychiatry, Melbourne Neuropsychiatry Centre, Melbourne, Australia
| | - Stanley N Caroff
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
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Thom RP, McDougle CJ. Case Reports: Clozapine for the Treatment of Catatonia in Autism Spectrum Disorder. J Autism Dev Disord 2021; 52:2855-2858. [PMID: 34283358 DOI: 10.1007/s10803-021-05149-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2021] [Indexed: 10/20/2022]
Abstract
Catatonia is a severe clinical syndrome which has been increasingly reported in autism spectrum disorder (ASD). The prevalence of catatonia in ASD is unknown. Diagnosing catatonia in ASD is complicated by overlapping clinical features such as mutism, stereotypies, and echophenomena. Here, we present the clinical histories of two individuals with ASD and catatonia who were successfully treated with clozapine. We have reported on a novel potential treatment option for catatonia in ASD. Additional studies are needed to evaluate the safety, efficacy, and tolerability of clozapine for the treatment of catatonia in ASD.
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Affiliation(s)
- Robyn P Thom
- Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA.,Lurie Center for Autism, 1 Maguire Road, Lexington, MA, 02421, USA.,Department of Psychiatry, Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - Christopher J McDougle
- Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA. .,Lurie Center for Autism, 1 Maguire Road, Lexington, MA, 02421, USA. .,Department of Psychiatry, Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA.
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Clozapine Withdrawal-Induced Malignant Catatonia or Neuroleptic Malignant Syndrome: A Case Report and a Brief Review of the Literature. Clin Neuropharmacol 2021; 44:148-153. [PMID: 34132673 DOI: 10.1097/wnf.0000000000000462] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
ABSTRACT In our brief literature review, we discuss the changes in the concept of catatonia as well as its various types and symptoms. We also succinctly review the possible symptoms of clozapine withdrawal. In addition, we analyze the main features of the very few published cases of clozapine withdrawal-induced catatonia and the relationship between neuroleptic malignant syndrome and the malignant subtype of catatonia. Furthermore, we present the case of a 29-year-old male patient with schizophrenia in whom a malignant catatonic episode/neuroleptic malignant syndrome (with negativism, stupor, mutism, autonomic signs [eg, fever, hyperhidrosis], and elevated creatine kinase levels) began 5 days after the patient decided arbitrarily to cease his clozapine treatment. His catatonic symptoms quickly (ie, within a few days) resolved after the reinstitution of clozapine. Finally, we attempt to provide a theoretical explanation for the surprising finding in the literature that the withdrawal of clozapine, unlike the withdrawal of any other antipsychotics, may be associated with catatonia (frequently its malignant subtype). The take-home message of our case is that clinicians should bear in mind the risk of catatonia (especially the malignant subtype of it) after the prompt withdrawal of clozapine therapy.
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Lucchelli JP, Kourakou S, Hasler G, Hilal R. Clozapine withdrawal catatonia in a young schizophrenic man. Encephale 2020; 47:396-398. [PMID: 33293035 DOI: 10.1016/j.encep.2020.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 09/10/2020] [Accepted: 09/28/2020] [Indexed: 10/22/2022]
Affiliation(s)
- J P Lucchelli
- Hôpital du Jura-bernois, pôle de santé mentale, Bellelay, Switzerland; Laboratoire de psychopathologie, E.A. 4050, université de Rennes 2, Rennes, France.
| | - S Kourakou
- Hôpital du Jura-bernois, pôle de santé mentale, Bellelay, Switzerland
| | - G Hasler
- University of Fribourg, Fribourg, Switzerland
| | - R Hilal
- Hôpital du Jura-bernois, pôle de santé mentale, Bellelay, Switzerland
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Ungvari GS, Gerevich J, Takács R, Gazdag G. Schizophrenia with prominent catatonic features: A selective review. Schizophr Res 2018; 200:77-84. [PMID: 28818505 DOI: 10.1016/j.schres.2017.08.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Revised: 08/03/2017] [Accepted: 08/07/2017] [Indexed: 02/07/2023]
Abstract
A widely accepted consensus holds that a variety of motor symptoms subsumed under the term 'catatonia' have been an integral part of the symptomatology of schizophrenia since 1896, when Kraepelin proposed the concept of dementia praecox (schizophrenia). Until recently, psychiatric classifications included catatonic schizophrenia mainly through tradition, without compelling evidence of its validity as a schizophrenia subtype. This selective review briefly summarizes the history, psychopathology, demographic and epidemiological data, and treatment options for schizophrenia with prominent catatonic features. Although most catatonic signs and symptoms are easy to observe and measure, the lack of conceptual clarity of catatonia and consensus about the threshold and criteria for its diagnosis have hampered our understanding of how catatonia contributes to the pathophysiology of schizophrenic psychoses. Diverse study samples and methodologies have further hindered research on schizophrenia with prominent catatonic features. A focus on the motor aspects of broadly defined schizophrenia using modern methods of detecting and quantifying catatonic signs and symptoms coupled with sophisticated neuroimaging techniques offers a new approach to research in this long-overlooked field.
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Affiliation(s)
- Gabor S Ungvari
- University of Notre Dame Australia/Marian Centre, 200 Cambridge Street, Perth 6014, Australia
| | - Jozsef Gerevich
- Addiction Research Institute, Remete u 12, Budapest, Hungary.
| | - Rozália Takács
- Psychiatric Outpatient Service, Toth Ilona Medical Service, Csiko setany 9, 1214 Budapest, Hungary; School of Doctoral Studies, Semmelweis University, Ulloi ut 85, 1085 Budapest, Hungary
| | - Gábor Gazdag
- 1st Department of Psychiatry and Psychiatric Rehabilitation, Jahn Ferenc Hospital, Koves ut 1, 1204 Budapest, Hungary; Department of Psychiatry and Psychotherapy, Faculty of Medicine, Semmelweis University, Balassa u 6, Budapest, Hungary.
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Lander M, Bastiampillai T, Sareen J. Review of withdrawal catatonia: what does this reveal about clozapine? Transl Psychiatry 2018; 8:139. [PMID: 30065280 PMCID: PMC6068101 DOI: 10.1038/s41398-018-0192-9] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 03/05/2018] [Accepted: 05/11/2018] [Indexed: 12/23/2022] Open
Abstract
Withdrawal symptoms are common upon discontinuation of psychiatric medications. Catatonia, a neuropsychiatric condition proposed to be associated with gamma-aminobutyric acid (GABA) hypoactivity due to its robust response to benzodiazepines, has been described as a withdrawal syndrome in case reports but is not a well-recognized phenomenon. The authors undertook a review of withdrawal catatonia with an aim to understand its presentation as well as the medications and psychoactive substances it is associated with. The review identified 55 cases of withdrawal catatonia, the majority of which occurred upon discontinuation of benzodiazepines (24 cases) and discontinuation of clozapine (20 cases). No other antipsychotic medications were identified as having been associated with the onset of a catatonic episode within 2 weeks following their discontinuation. Increasing GABA activity and resultant GABA receptor adaptations with prolonged use is postulated as a shared pharmacological mechanism between clozapine and benzodiazepines that underlie their association with withdrawal catatonia. The existing evidence for clozapine's activity on the GABA system is reviewed. The clinical presentations of benzodiazepine withdrawal catatonia and clozapine withdrawal catatonia appear to differ and reasons for this are explored. One reason is that benzodiazepines act directly on GABAA receptors as allosteric agonists, while clozapine has more complex and indirect interactions, primarily through effects on receptors located on GABA interneurons. Another possible reason for the difference in clinical presentation is that clozapine withdrawal catatonia may also involve receptor adaptations in non-GABA receptors such as dopamine and acetylcholine. The findings from our review have implications for the treatment of withdrawal catatonia, and treatment recommendations are provided. Further research understanding the uniqueness of clozapine withdrawal catatonia among antipsychotic medication may give some insight as to clozapine's differential mechanism of action.
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Affiliation(s)
- Matthew Lander
- Department of Psychiatry, University of Manitoba, Winnipeg, Canada.
| | - Tarun Bastiampillai
- Discipline of Psychiatry, School of Medicine, Flinders University, Adelaide, Australia
- South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Jitender Sareen
- Departments of Psychiatry, Psychology, and Community Health Sciences, University of Manitoba, Winnipeg, Canada
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Doran E, Sheehan JD. Acute catatonia on medical wards: a case series. J Med Case Rep 2018; 12:206. [PMID: 29976243 PMCID: PMC6034265 DOI: 10.1186/s13256-018-1714-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 05/11/2018] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Catatonia is a behavioral syndrome which presents with an inability to move normally. It is associated with mood disorders and schizophrenia, as well as with medical and neurological conditions. It is an expression of the severity of the underlying condition. The awareness of catatonia among general medical doctors and even psychiatrists is poor. It is often seen as an historical diagnosis. Because of this, catatonia is often not recognized. If patients in catatonic states are not diagnosed, their condition is likely to progress with a risk of increased morbidity and potentially fatal outcomes. CASE PRESENTATION We present a case series of three acutely unwell, frail, elderly medical patients (a 65-year-old Irish woman, a 75-year-old Irish woman, and a 68-year-old Irish woman) with a background of longstanding well-controlled psychiatric illnesses, who developed acute catatonia while being treated for medical conditions in a general medical in-patient setting. CONCLUSIONS Catatonia is common in acute medical settings but is underdiagnosed due to the low awareness of the condition among both general medical doctors and psychiatrists. Within a short time period, we diagnosed and successfully treated three acutely unwell patients in acute medical settings. We would like to increase the awareness of catatonia among medical doctors.
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Plevin D, Mohan T, Bastiampillai T. The role of the GABAergic system in catatonia-Insights from clozapine and benzodiazepines. Asian J Psychiatr 2018; 32:145-146. [PMID: 29272785 DOI: 10.1016/j.ajp.2017.12.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 12/13/2017] [Accepted: 12/14/2017] [Indexed: 11/29/2022]
Affiliation(s)
- David Plevin
- Flinders Medical Centre, Bedford Park, SA 5042, Australia.
| | - Titus Mohan
- Flinders Medical Centre, Bedford Park, SA 5042, Australia
| | - Tarun Bastiampillai
- South Australian Health and Medical Research Institute (SAHMRI) - Mind and Brain, Adelaide, Australia
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Abstract
LEARNING OBJECTIVES After participating in this activity, learners should be better able to:• Assess the etiologies associated with catatonia in children and adolescents• Evaluate the differential diagnosis of pediatric catatonia• Interpret the literature regarding the treatment of children and adolescents with catatonia OBJECTIVE: Pediatric catatonia is associated with many medical and psychiatric conditions. Mortality is high, and proper treatment can be lifesaving. Catatonia is increasingly recognized in pediatric populations, in which about 20% of cases are related to underlying medical conditions. To minimize morbidity, clinicians must rule out underlying disorders while simultaneously managing symptoms and causes. In our review we discuss (1) recommendations to aid rapid decision making, both diagnostic and therapeutic, (2) emergent conditions and management, (3) disorders associated with pediatric catatonia, including developmental, acquired, idiopathic, and iatrogenic etiologies, (4) available treatments, and (5) medicolegal considerations. METHODS Initial PubMed search without date constraints using MeSH terms related to pediatric catatonia, with subsequent searches on pertinent subtopics using PubMed and Google Scholar. RESULTS Pediatric catatonia is a dangerous but treatable neuropsychiatric condition. Psychiatrists need to be aware of differential diagnoses and to be able determine appropriate treatment within a short time frame. With prompt diagnosis and treatment, outcomes can be optimized. CONCLUSION Pediatric catatonia is underdiagnosed and requires rapid evaluation and management.
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Beach SR, Gomez-Bernal F, Huffman JC, Fricchione GL. Alternative treatment strategies for catatonia: A systematic review. Gen Hosp Psychiatry 2017; 48:1-19. [PMID: 28917389 DOI: 10.1016/j.genhosppsych.2017.06.011] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 06/19/2017] [Accepted: 06/22/2017] [Indexed: 01/03/2023]
Abstract
BACKGROUND Catatonia is a commonly encountered syndrome, affecting 10-20% of various psychiatric populations and carrying significant medical co-morbidities. However, there are few established alternative treatment strategies when benzodiazepines are ineffective and electroconvulsive therapy is unavailable. OBJECTIVE The authors systematically review evidence for alternative treatment strategies for catatonia using Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. METHOD The authors conducted a search of PubMed database from 1983 to August 2016 to identify articles. Eligible reports presented cases involving treatment of catatonia using modalities other than benzodiazepines or electroconvulsive therapy. RESULTS The authors identified 72 articles, comprising 98 individual cases. N-methyl-d-aspartate-receptor antagonists, anti-epileptic drugs, and atypical antipsychotic agents appeared to have the largest number of reports supporting their effectiveness and safety in treating catatonia patients. CONCLUSIONS Based on the case report literature, the authors propose an updated algorithm for catatonia treatment in cases where benzodiazepines fail and electroconvulsive therapy is not available.
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Affiliation(s)
- Scott R Beach
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States.
| | | | - Jeff C Huffman
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Gregory L Fricchione
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
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16
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Affiliation(s)
- Karim Tabbane
- From the Faculty of Medicine, Razi Hospital, La Manouba, Tunisia (Tabbane, Halayem); and the Department of Psychiatry, McGill University, Montreal, Que., Canada (Joober)
| | - Soumeyya Halayem
- From the Faculty of Medicine, Razi Hospital, La Manouba, Tunisia (Tabbane, Halayem); and the Department of Psychiatry, McGill University, Montreal, Que., Canada (Joober)
| | - Ridha Joober
- From the Faculty of Medicine, Razi Hospital, La Manouba, Tunisia (Tabbane, Halayem); and the Department of Psychiatry, McGill University, Montreal, Que., Canada (Joober)
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17
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Lin CC, Hung YY, Tsai MC, Huang TL. Relapses and recurrences of catatonia: 30-case analysis and literature review. Compr Psychiatry 2016; 66:157-65. [PMID: 26995249 DOI: 10.1016/j.comppsych.2016.01.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 11/27/2015] [Accepted: 01/16/2016] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE Relieving catatonia helps identify the underlying etiology and its treatment. However, catatonia may reemerge after some time, but there are few data on the relapses and recurrences of catatonia. We aimed to investigate the characteristics of patients with relapses or recurrences of catatonia as well as the efficacy of the lorazepam-diazepam protocol on them. METHODS Patients with catatonia who had more than one episode of catatonia and were treated with the lorazepam-diazepam protocol were identified. Their medical charts were reviewed, and interview was conducted. RESULTS Thirty patients were identified. Nineteen (63.3%) were diagnosed with schizophrenia, five (16.7%) with major depressive disorder, two (6.7%) with bipolar disorder, and four (13.3%) with general medical conditions. In the 68 relapses and relapses the lorazepam-diazepam protocol was used, full response was reported in 54 (79.4%) of them. Twelve of 19 (63.2%) patients with schizophrenia were treated with clozapine. Twenty (66.7%) out of 30 patients were maintained on oral lorazepam by the time of discharge. Literature review showed similar prevalence of schizophrenia in patients with more than one episode of catatonia, and a wide variety of treatment options. CONCLUSION The lorazepam-diazepam protocol was mostly effective in managing relapses and recurrences of catatonia. Maintenance clozapine and oral lorazepam were beneficial in a significant number of patients.
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Affiliation(s)
- Chin-Chuen Lin
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yi-Yung Hung
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Meng-Chang Tsai
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Tiao-Lai Huang
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.
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Ahuja N, Cole A. Practical approach to management of catatonia. FUTURE NEUROLOGY 2015. [DOI: 10.2217/fnl.15.39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
In this article, we discuss important issues in the management of catatonic symptoms in busy clinical settings. Catatonic symptoms are common among inpatients, not only in psychiatry but also in acute medicine and neurology. Prompt recognition of these symptoms is easy if clinicians maintain a high index of suspicion. Early diagnosis and treatment can reduce the significant morbidity and mortality associated with these cases. Speedy investigation to rule out organic catatonia and identify dangerous complications forms an important part of management. Early treatment with benzodiazepines can aid diagnosis and shorten the duration of catatonia, thereby improving outcomes. Electroconvulsive therapy has an important role where benzodiazepines have been ineffective, but antipsychotics can be potentially harmful. There are a number of other treatment options that are less robustly evidence-based, but supportive management is essential in all cases.
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Affiliation(s)
- Niraj Ahuja
- Northumberland, Tyne & Wear NHS Foundation Trust, Northumberland, Tyne & Wear NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Andrew Cole
- Northumberland, Tyne & Wear NHS Foundation Trust, Northumberland, Tyne & Wear NHS Foundation Trust, Newcastle Upon Tyne, UK
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Wijemanne S, Jankovic J. Movement disorders in catatonia. J Neurol Neurosurg Psychiatry 2015; 86:825-32. [PMID: 25411548 DOI: 10.1136/jnnp-2014-309098] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Accepted: 10/28/2014] [Indexed: 12/13/2022]
Abstract
Catatonia is a complex neuropsychiatric syndrome characterised by a broad range of motor, speech and behavioural abnormalities. 'Waxy flexibility', 'posturing' and 'catalepsy' are among the well-recognised motor abnormalities seen in catatonia. However, there are many other motor abnormalities associated with catatonia. Recognition of the full spectrum of the phenomenology is critical for an accurate diagnosis. Although controlled trials are lacking benzodiazepines are considered first-line therapy and N-Methyl-d-aspartate receptor antagonists also appears to be effective. Electroconvulsive therapy is used in those patients who are resistant to medical therapy. An underlying cause of the catatonia should be identified and treated to ensure early and complete resolution of symptoms.
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Affiliation(s)
- Subhashie Wijemanne
- Department of Neurology, Parkinson's Disease Center and Movement Disorders Clinic, Baylor College of Medicine, Houston, Texas, USA
| | - Joseph Jankovic
- Department of Neurology, Parkinson's Disease Center and Movement Disorders Clinic, Baylor College of Medicine, Houston, Texas, USA
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