Electroconvulsive Therapy For Malignant Catatonia Due To Clozapine Withdrawal—A Case Series

Background

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

Objectives

To identify and present new cases of malignant catatonia secondary to clozapine withdrawal that were successfully treated with electroconvulsive therapy.

Methods

We present a series of 3 cases (3 case reports) 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.

Conclusion

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