Zolpidem in treatment resistant adolescent catatonia: a case series

Abstract

Catatonia is a well-established psycho-motor disorder occurring in the background of various psychiatric and medical disorders. Catatonia is commonly associated with psychiatric disorders, especially affective disorders followed by schizophrenia. However, almost 20% occur in the background of different medical and neurological disorders which need to be properly examined and investigated. Catatonia is a serious medical and psychiatric emergency condition; most probably caused by alteration in GABAergic circuits and basal ganglia. If untreated, catatonia can cause life threatening complications like dyselectrolemia, respiratory aspiration, venous thromboembolism, acute renal failure and cardiac arrest because of poor oral intake, immobility and muscular rigidity. The risk of mortality or serious life threatening events further increases in cases of children and adolescents. In children and adolescents, thus, it becomes even more important to diagnose catatonia early and start appropriate treatment. Lorazepam is considered to be the first line treatment and is safe both in adults and children. But evidence is scarce for treatment of lorazepam-resistant adolescent Catatonia. In this report we discuss two adolescent patients diagnosed with catatonia with no medical or neurological disorders in the background. Neither of the patients responded to lorazepam alone or even after augmentation with second generation antipsychotic (olanzapine). Zolpidem, like lorazepam, has a positive allosteric effect on GABA A Receptors (GABAAR) and has been used in some cases successfully to treat resistant catatonia. Here we used zolpidem 30 mg/day in divided doses with marked improvement in few days in all the symptoms. Both cases were discharged on zolpidem extended release (ER) three times a day and maintained well through the next two follow ups in over a two month period. Zolpidem can be a good alternative for children and adolescents in resistant cases.

Evidence-based consensus guidelines for the management of catatonia: Recommendations from the British Association for Psychopharmacology

“…Mastain et al (1995) described a serendipitous dramatic response to oral zolpidem 10 mg in a woman with a subcortical stroke whose catatonia was largely unresponsive to lorazepam or ECT. This was followed by other positive reports ( Amorim and McDade, 2016 ; Baptista and Choucha, 2019 ; Bastiampillai et al, 2016 ; Isomura et al, 2013 ; Javelot et al, 2015 ; Kumar and Kumar, 2020 ; Peglow et al, 2013 ; Sayadnasiri and Rezvani, 2019 ; Seetharam and Akerman, 2006 ; Thomas et al., 1997 ; Zaw and Bates, 1997 ). The response is transitory, as with benzodiazepines, and is usually observed for 3–6 h ( Bastiampillai et al, 2016 ; Thomas et al., 2007 ), which is consistent with zolpidem’s short elimination half-life of 1–4 h ( Hiemke et al, 2018 ).…”

Zolpidem in Elderly Patients With Acute Treatment Resistant Catatonia: A Case Report

“…11,12 The literature describes a total of 3 case reports-patients ages 14 and 15-in which 2 had complete resolution of catatonic symptoms and another had significant improvement (greater than a 15 point reduction in BFCRS). 11,12 In addition to adolescents, older adults (over 65) with catatonia have responded favorably to zolpidem. [13][14][15] Furthermore, in addition to cases of acute catatonia, one case report suggests zolpidem can be effective in chronic catatonia.…”

“…16 Finally, Zolpidem has been observed to provide complete remission of catatonia among patients with concurrent psychiatric disorders (such as schizoaffective disorder or bipolar disorder). 12,17 Specifically, a dose of oral zolpidem of 10 to 40 mg daily was administered to a 46-year-old man with schizoaffective disorder, with complete remission of catatonia. 17 Likewise, a patient with catatonia and a concurrent bipolar disorder responded completely to zolpidem treatment.…”

“…This case report describes the efficacy, safety, and dosing considerations for zolpidem for an elderly patient with catatonia. 12 Two validated screening tools, the Beers Criteria and STOPP/START criteria assist providers in reconciling medications that may pose risks for elderly patients. There is significant overlap between the 2 tools, however STOPP is noted to place more emphasis on drug interactions and avoid duplicates of a drug class.…”

Oral and Intranasal Ketamine Use in Treatment-Resistant Catatonia: A Clinical Case Report

“…If benzodiazepines are ineffective, electroconvulsive therapy (ECT) is considered second line and could be highly successful. A limited number of case reports have shown NMDA antagonists amantadine and memantine, as well as the nonbenzodiazepine hypnotic zolpidem, to improve catatonic symptoms [11][12][13].…”