The multi-modal treatment of catatonia: Targeting multiple receptors when GABA-based benzodiazepines fail

Abstract

The family brought a 48-year-old woman with major depressive disorder to the emergency room due to unresponsiveness and bizarre behavior. Catatonia was suspected and confirmed by a positive lorazepam challenge test. The patient’s home regimen included bupropion, though the family reported non-adherence. Intravenous lorazepam was scheduled, and the patient’s catatonic symptoms gradually improved. Gradual tapering of lorazepam caused the re-appearance of catatonic symptoms. Each attempt at tapering lorazepam resulted in catatonic symptoms resurfacing and requiring higher scheduled doses of lorazepam. Electroconvulsive treatment was not an option as (1) it was not easily accessible, and (2) the patient did not consent. Multiple anti-depressants were tried and discontinued due to intolerable side effects, and the patient eventually partially improved with mirtazapine, zolpidem, memantine, and lorazepam. Catatonia is a complex neuropsychiatric syndrome that requires prompt recognition, diagnosis, and treatment. Such cases pose a challenge to physicians. Our case emphasizes considering the uniqueness of each individual’s presentation of chronic catatonia during treatment.