
- Vol 40, Issue 2
Research Explores the Efficacy of Clozapine as a Treatment for Catatonia
There is very modest evidence that clozapine may be associated with improvement of catatonia.
CASE VIGNETTE
“Mrs Brick” is a 56-year-old Caucasian female with a history of chronic schizophrenia. She had been stable on a medication regimen of risperidone 4 mg at bedtime and citalopram 20 mg in the morning. In the previous 6 months, however, she had lost her mother to cardiovascular disease and her brother, who died within 2 months of a cancer diagnosis. Mrs Brick’s husband took her to the emergency department because of deficits in self-care. Mrs Brick had not been eating well and had lost 15 pounds in 2 months. She had low energy and poor concentration. She had been isolating in bed most of the time and she required significant prompting to attend to personal hygiene. On exam, it was discovered that she had profound psychomotor retardation, poverty of speech, and increased latency of response. She also exhibited some mild posturing.
Mrs Brick was admitted to the inpatient psychiatric unit. Laboratory studies were unremarkable. She was started on lorazepam 1 mg 3 times daily for catatonia and her risperidone was increased to 6 mg. After 3 days, her condition remained largely unchanged. Subsequently, her psychiatrist started her on
The atypical antipsychotic clozapine, with its unique pharmacologic profile, including relatively weaker dopamine D2 receptor antagonism, represents a potential treatment for both catatonia and underlying psychosis. There is also evidence for catatonia following clozapine withdrawal.4 However, evidence for clozapine as a potential treatment for catatonia has not been systematically reviewed.
The Current Study
Saini and colleagues performed a systematic review of clozapine in the treatment of catatonia.5 The authors used the NICE Healthcare databases to search Medline, EMBASE, PubMed, PsycINFO, and CINAHL from inception through June 2021. They included English-language, original, full-text studies in peer-reviewed journals; the looked at all study designs with at least 1 patient with catatonia treated with clozapine, although case reports and case series were grouped separately. Studies were excluded if catatonia was not identified by a clinician or catatonia occurring in the context of neuroleptic malignant syndrome, or where maintenance clozapine was used only for secondary prophylaxis of
The authors identified 849 studies from initial searches, of which 93 were included. This consisted of 79 case reports, 8 case series, and 6 cohort studies. The final sample treated with
In the case reports and case series, the mean age was 35 years (but the age range was broad), 65% were male, and 63% had schizophrenia or related psychosis.
Study Conclusions
Full or partial remission rates were 84% in cohort studies and 81% in case reports or case series, with treatment over a period of weeks to months. The mean peak dose of clozapine was 322 mg. A major limitation is the absence of any controlled treatment trials, which precluded the use of meta-analysis. Also, data on blood clozapine levels were not available for the majority of patients. There may have been potential confounding by other psychotropic medications. The main study strength is that it is the first systematic review of clozapine for the treatment of catatonia.
The Bottom Line
There is very modest evidence that clozapine may be associated with improvement of
Dr Miller is a professor in the Department of Psychiatry and Health Behavior at Augusta University in Augusta, Georgia. He is on the editorial board and serves as the schizophrenia section chief for Psychiatric Times™. The author reports that he receives research support from Augusta University, the National Institute of Mental Health, and the Stanley Medical Research Institute.
References
1. Sienaert P, Dhossche DM, Vancampfort D, et al.
2. Solmi M, Pigato GG, Roiter B, et al.
3. Guidance on the use of electroconvulsive therapy. National Institute for Health and Care Excellence. April 26, 2003. Accessed December 13, 2022.
4. Lander M, Bastiampillai T, Sareen J.
5. Saini A, Begum N, Matti J, et al.
6. Murad MH, Sultan S, Haffar S, Bazerbachi F.
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