cataonia

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randomdoc1

randomdoc1

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I have seen cases in residency training and am aware treatment options include benzodiazepines and ECT. I have a 70 yo female, bipolar I. For many years, stable on a combination of tegretol (which I read can also help with bipolar depression and lithium). These were discontinued by a previous provider due to development of hyperparathyroidism. We've tried other medications such as olanzapine with fluoxetine, latuda, and seroquel for bipolar depression. Unfortunately, nothing seems to have touched her bipolar depression anywhere near as well as the tegretol with lithium. Over this fall, she developed a psychotic depression with catatonia. I have seen her once in the summer with a full blown manic episode. Now the lorazepam finally lysed the catatonia and we've decided to just go back to lithium with tegretol although last time I tried lithium again, her PTH did increase. But in discussing risks versus benefits, I may just have to work closely together with her endocrinologist. Question is, with catatonia, my understanding from reading is you continue the therapeutic dose of the lorazepam for 3-6 months and then taper? Unfortunately in residency, I did not seen outpatient continued management of patients who recovered from catatonia. Also, what if we have to revisit antipsychotics again? Since they can worsen catatonia, would she need to be on maintenance benzodiazepines potentially or should I start an antipsychotic (if for whatever reason the lithium with tegretol does not work out anymore) with no benzodiazepine and provide it prn? I'm embarrassed to ask this but figured it wouldn't hurt to ask of others who managed catatonia as well.
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All good questions. Benzos in a geriatric patient carry the risk of increased falls, pneumonia, cognitive deficits, etc. Antipsychotics have their own risks, too. There is less data in this area to guide you with clear answers. Wade thru the mud with open frank risk benefits discussion with patient. Let the patient decide.

You have several treatment options/permutations to pick from. If you have ECT access in your area that could be your rescue plan B, and allow for a more med conservative plan A?
 
That's what I was thinking too. To make this case even more interesting, she already had a fall and hit her head (has been medically cleared/followed). But she regresses into catatonia on a dose decrease. woo....tough one. she's still resistant to ECT but we will have a continued discussion.
 
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Any memantine on board during/after catatonia? Something to think about as potential option down the line. Not sure of any literature out there for it being utilized as a subacute maintenance medication (for catatonia) but have seen it work quite well early on in treatment.

Risk vs benefits regarding the Lithium and Tegretol. Solid call getting endo on board.

How high were the dosages on fluoxetine/olanzapine, lurasidone, quetiapine?

Try Lamictal at all previously, alone or in combination?

Are we sure that these depressed episodes (outside of those when she obviously presents with catatonia) are simply depression and not subtle catatonia all along? Could this be multifactorial psychomotor ******ation during some of these episodes? Any signs of baseline neurocognitive deficits? Findings on neuro exam? Recent imaging? Does she eat well (a non-ETOH induced Wernicke's type of picture that may respond to high dose thiamine)? The resistance to tx makes me wonder if there is more going on than assumed. Could be wrong but worth the thought (and certainly more to add to the differential here).

As far as antipsychotics, I'm not sure there would be any problem starting one outside of those times she is riding a full-blown catatonic wave. I know there is a camp who are very hesitant using antipsychotics peri-catatonia but once those subcortex motor gears get greased up and symptoms start improving antipsychotics could very well be indicated in many cases.

Keep updating us on this one. Interesting case.
 
Thanks @Dharma! The namenda is an interesting mention, I will have to look into it. So in the fall, she was on 300 seroquel qhs, lamictal 100mg/day, and tegretol 200mg bid. She felt very depressed in fall and started to have lower energy, wanted to sleep all the time, anhedonia, and poor concentration. She was still quite alert and able to interact. I increased the seroquel but was limited because she was starting to complain of excessive sedation from it. So I changed the seroquel out for lithium. It was titrated into the therapeutic range for 6 weeks. So we had the lithium and lamictal (up to 200mg/day) combination and i did take away the tegretol as i did not want her to have the polypharmacy. Remained depressed but not catatonic. Progressively we started to notice the psychotic thoughts. She was convinced she was dying in the near future and accused her husband of stealing her purse. Fluoxetine I had gone up to 50mg/day and olanzapine 7.5mg. She had the most response to that but reported still feeling very depressed, had psychomotor ******ation and wanted to isolate all the time. After 4 weeks, it seemed like her progress had already plateaued early on. Latuda I only tried at 40mg/day but when I switched her from symbyax to latuda, she precipitously declined so we did not continue with that. I sent her to inpatient because she was so catatonic: she had pronounced psychomotor ******ation, lacked tremendously in spontaneity to the point where husband was concerned about her ability to keep herself sufficiently nourished, she barely responded to yes or not questions. We gave her the lorazepam challenge and she went hypomanic. Currently on:
lithium 150mg bid (that's usually the therapeutic dose for her)
tegretol 200mg bid (that usually gets her in the lower end of the therapeutic range)
ativan 0.5mg tid (she had a fall on this dose)--seems to be slipping back into catatonia now.

At baseline, pretty well functioning, spunky and a spitfire. Independent, drives, does all IADL and generally very social. She's had extensive medical work up including blood work, TSH, UA, and CTOH. She generally eats well but the 2 weeks prior to admission were a challenge. She is maintaining her weight though but husband had to do tons of prompting.

I'm baffled at the treatment resistance too! But over the time I have known her, she is certainly a true blue bipolar I. No whiff of axis II and she lives with her husband. They seem to have a healthy dynamic and her medical history was pretty uneventful except for some HTN. I'm really eager to see what happens after the ECT. The inpatient team is in agreement with me that it seems to be the most logical step.

Patient has literally had decades of stability on lithium with tegretol. But once that was taken out after her hyperparathyroidism, she's had more peaks and valleys in her mood. I often found her on the slightly hypomanic side, and have worked on gradually increasing her mood stabilizing agents but conservatively as she's fallen out of therapeutic and into toxic range on her tegretol and lithium in the past (especially as she got older and other medications like BP medications were introduced).
 
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Is there a reason you haven't tried clozapine yet? The evidence base for using it to treat stubborn catatonia is just as good as for namenda. It also definitely has a place in treatment-resistant bipolar I, especially if she is so quick to become psychotic when ill. Plus, very unlikely to push her back into catatonia. She sounds very functional with food supports when at baseline so the monitoring process should not be impossible (she's already used to regular bloodwork for lithium, no?).

Might also want to think about supraphysiologic thyroid supplementation since we are deep into the weeds of treatment off the beaten path. I am sure any Endo you work with will feel some kind of way about that, though.
 
Patient completed her course of ECT. She is doing MARVELOUS! Back to baseline and spunky. Hopefully going back to her old regimen helps for maintenance purposes. Will keep folks posted on if there is recurrence. But WOW, ECT is the MAN.
 
randomdoc1 said:
Patient completed her course of ECT. She is doing MARVELOUS! Back to baseline and spunky. Hopefully going back to her old regimen helps for maintenance purposes. Will keep folks posted on if there is recurrence. But WOW, ECT is the MAN.
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So much more interesting when we get updates like this, so thank you!
 
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