(025) Electroconvulsive Therapy For Malignant Catatonia Due to Clozapine Withdrawal: A Case Series

Location: Griffin Hall

Trainee Involvement: Yes

Presenting Author(s)

Andrew J. Spitzberg, MD

Psychiatry Resident
Zucker Hillside Hospital
Glen Oaks, New York, United States

Co-Author(s)

SA

Sean Allan, MD, FACLP

Attending Psychiatrist
Zucker Hillside Hospital, Northwell Health
Glen Oaks, New York, United States
HS

Humaira Shoaib, MD

Consultation-Liaison Psychiatrist
Long Island Jewish Medical Center, Northwell Health
New Hyde Park, New York, United States
jd

joanna drucker, PMHNP-BC

Nurse Practitioner
Long Island Jewish Medical Center
merrick, New York, United States
Xavier Jimenez, MD, MA, FACLP

Director, Consultation Liaison Psychiatry
Long Island Jewish Medical Center (Northwell)
New Hyde Park, New York, United States
GP

Georgios Petrides, MD

Director Division of ECT, Zucker Hillside Hospital,
Northwell Health System
New York, New York, United States
SS

Sohag Sanghani, MD, FAAGP, MPH

Director, ECT Service. Asst Professor
Zucker School of Medicine at Hofstra/Northwell
Glen Oaks, New York, United States

Background:
Clozapine, a pharmacologically complex second-generation antipsychotic, is the standard of care for treatment resistant schizophrenia.1 Abrupt cessation of clozapine can lead to severe medical complications like cholinergic rebound, psychiatric decompensation, and the development or reappearance of catatonia.1 Malignant catatonia, an acute and life-threatening form of catatonia with autonomic dysfunction and instability, has been observed to occur secondary to clozapine withdrawal.2 Malignant catatonia has a significant mortality rate and requires prompt diagnosis and treatment with lorazepam and/or electroconvulsive therapy.2 There have been few published cases observing malignant catatonia secondary to clozapine withdrawal, and even fewer cases reporting successful treatment with electroconvulsive therapy. In this case series we aim to identify and present new cases of a malignant catatonia secondary to clozapine withdrawal that were successfully treated with electroconvulsive therapy.

Methods:
We present 3 case studies of patients who developed catatonic symptoms with autonomic instability after abruptly discontinuing clozapine.

Results:
In all three cases, malignant catatonia was diagnosed and initially treated with lorazepam with little effect. With worsening autonomic instability and catatonic symptoms, and minimal improvement with lorazepam, patients were ultimately effectively treated with electroconvulsive therapy.

Discussion:
Malignant catatonia should be considered early in patients presenting with catatonic symptoms, abnormal behavior, and autonomic dysfunction in the setting of abrupt clozapine discontinuation. Although the first line treatment for catatonia and malignant catatonia is lorazepam, benzodiazepine medications alone may not be sufficient in cases of clozapine withdrawal.

Conclusion/Implications:
Electroconvulsive therapy has been shown to be an effective treatment in managing malignant catatonia in the setting of clozapine withdrawal.

References:

Haidary HA, Padhy RK. Clozapine. StatPearls Publishing; 2021. Accessed August 30, 2022. https://www.ncbi.nlm.nih.gov/books/NBK535399/
Bilbily J, McCollum B, de Leon J. Catatonia Secondary to Sudden Clozapine Withdrawal: A Case with Three Repeated Episodes and a Literature Review. Case Rep Psychiatry. 2017;2017:2402731. doi:10.1155/2017/2402731