The catatonic syndrome: clinical features and ECT response of 26 in-patients resistant to pharmacological treatment

Recent evidence has been brought in favor to the view of catatonia as an autonomous syndrome, frequently associated with mood disorders. Catatonia responds specifically to benzodiazepines and electroconvulsive therapy (ECT). ECT is first-line treatment in malignant catatonia and in case of resistance to benzodiazepines, leading to remission in 85-89% of cases. In this study the data deriving from the examination of the medical records of 26 catatonic in-patients are presented. All subjects were referred to ECT for resistance to pharmacological treatments. They were systematically evaluated before ECT and after the ECT course with Bush-Francis Catatonia Rating Scale (BFCRS), Brief Psychiatric Rating Scale (BPRS), Young Mania Rating Scale (YMRS) and Clinical Global Improvement (CGI). The variation in psychotic symptomatology was investigated using BPRS psychotic cluster score. All records were scrutinized for demographic, clinical and treatment-related features. All patients had a current diagnosis of mood disorder: 7 (26.9%) patients presented with bipolar major depression with psychotic features and 19 (73.1%) with mixed state with psychotic features. The ECT-response rate was 80.8%, where response was defined as a CGI-Improvement subscale rating 1 (“very much improved”) or 2 (“much improved”). In spite of the small sample size, a comparison between responders to ECT (n=21) and non-responders (n=5) was conducted in order to explore possible features associated with non-response to ECT. In comparison with responders, non-responders presented a later onset of the underlying mood disorder, less previous mood episodes and were more frequently treated with anticholinergic and dopamine-agonists drugs before developing catatonic symptoms. Moreover, non-responders presented a statistically significant higher BFCRS total score at baseline, a non-statistically significant lower BPRS psychotic cluster score at baseline, especially in the items “unusual thought content” and “conceptual disorganization”, and a statistically significant lower score in the item “thought content” of YMRS. Finally, non-responder catatonic patients more likely presented at baseline with gegenhalten as identified with BFCRS. Conversely, the responder group was more frequently treated with typical antipsychotics before developing catatonic symptoms and presented at baseline with withdrawal as identified with BFCRS. Catatonia is a severe clinical syndrome frequently associated with bipolar disorder, in particular with psychotic mixed states. ECT resulted very effective in most of our catatonic patients with mood disorders. Severe psychotic symptoms such as delusions and conceptual disorganization seem to be associated with favorable response to ECT, while late onset, less episodes of mood disorders and gegenhalten may be considered as predictors of non-response. The higher use of anticholinergic and dopamine-agonists drugs in the non-responders in comparison to responders suggest a possible role of a reduced sensitivity of the nigro-striatal dopaminergic system in the pathogenesis of a putative ECT resistant subtype of catatonia. The major limitation of the present study is the low number of subjects classified as non-responders. Given the high possibility of both type-I and type-II error, our results should be considered preliminary. Further studies on larger sample are necessary to confirm these preliminary findings