Cases That Test Your Skills

When clozapine is not an option

Current Psychiatry. 2006 September;5(9):98-110

References

1. Diagnostic and statistical manual of mental disorders, 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000:204.

2. Ungvari GS, Leung SK, Ng FS, et al. Schizophrenia with prominent catatonic features (“catatonic schizophrenia”) I. Demographic and clinical correlates in the chronic phase. Prog Neuropsychopharmacol Biol Psychiatry 2005;29:27-38.

3. Dhossche D, Wing L, Ohta M, Neumarker K (eds). Catatonia in autism spectrum disorders. International review of neurobiology, vol. 72. San Diego: Elsevier/Academic Press; 2006.

4. Falkai P, Wobrock T, Lieberman J. WFSBP guidelines for biological treatment of schizophrenia, part 1. Acute treatment of schizophrenia. World J Biol Psychiatry 2005;6:32-91.

5. Van Dalfsen F, Van Hecke J, Van Dalfsen A, et al. The use of atypical antipsychotics in the treatment of catatonia. Eur Psychiatry 2005;20:422-9.

6. Rosebush PI, Hildebrand AM, Furlong BG, Mazurek MF. Catatonic syndrome in a general psychiatric inpatient population: frequency, clinical presentation, and response to lorazepam. J Clin Psychiatry 1990;51:357-62.

7. Dursun SM, Hallak JE, Haddad P, et al. Clozapine monotherapy for catatonic schizophrenia: should clozapine be the treatment of choice, with catatonia rather than psychosis as the main therapeutic index? J Psychopharmacol 2005;19:432-3.

8. White DAC, Robbins AH. An analysis of 17 catatonic patients diagnosed with neuroleptic malignant syndrome. CNS Spectrums 2000;5:58-65.

9. Sachdev PS. A rating scale for neuroleptic malignant syndrome. Psychiatry Res 2005;135:249-56.

10. Northoff G. Catatonia and neuroleptic malignant syndrome: psychopathology and pathophysiology. J Neural Transm 2002;109:1453-67.

11. Francis A, Chandragiri S, Rizvi S, et al. Is lorazepam a treatment for neuroleptic malignant syndrome? CNS Spectrums 2000;5:54-7.

12. Bush G, Fink M, Petrides, et al. Catatonia I: Rating scale and standardized examination. Acta Psychiatr Scand 1996;93:129-36.

13. Carroll BT, Thomas C, Jayanti K, et al. Schizophrenia with catatonic features deserves further study. World J Biol Psychiatry 2005;6(4):267-8.

14. Ungvari GS, Chie HFK, Chow LY, et al. Lorazepam for chronic catatonia: A random, double blind, placebo-controlled cross-over study. Psychopharmacology (Berl) 1999;142:393-8.

15. Salokangas R, Honkonen T, Stengard E, et al. Negative symptoms and neuroleptics in catatonic schizophrenia. Schizophr Res 2003;59:73-6.

16. Fink M, Taylor MA. Catatonia: a clinician’s guide to diagnosis and treatment. Cambridge, UK: Cambridge University Press; 2003.

17. Franz M, Gallhofer B, Kanzow WT. Treatment of catatonia with intravenous biperidine. Br J Psychiatry 1994;164:847-8.

18. Northoff G, Eckert J, Fritze J. Glutamatergic dysfunction in catatonia? Successful treatment of three acute akinetic catatonic patients with the NMDA antagonist amantadine. J Neurol Neurosurg Psychiatry 1997;62:404-6.

19. Thomas C, Carroll BT, Maley JT, et al. Memantine in catatonic schizophrenia. Am J Psychiatry 2005;162:656.

20. Carroll BT, Thomas C, Jayanti K. Amantadine and memantine in catatonic schizophrenia. Ann Clin Psychiatry 2006;18:133-4.

21. Carpenter SS, Hatchett AD, Fuller MA. Catatonic schizophrenia and the use of memantine. Ann Pharmacother 2006;40:344-6.

We see Mr. S monthly. He is still impulsive at times, occasionally collecting his neighbors’ newspapers and mail despite instructions from group home staff not to do so. Yet his sponsors say Mr. S is “like a new person.” He talks spontaneously, interacts, and is cooperative. He has not been hospitalized for more than 1 year.

The authors’ observations

Mr. S responded favorably to clozapine but cannot tolerate it. With a combination of two other SGAs, a patient might gain the benefits of clozapine without the need for frequent blood draws or the risk of agranulocytosis, other side effects, or interactions between clozapine and other drugs. Adding memantine was necessary to improve the catatonic features that prevented his return to the group home.

Related resources

World Federation of Societies of Biological Psychiatry. www.wfsbp.com.
Neuroleptic Malignant Syndrome Information Service. www.nmsis.org.
Mann SC, Caroff SN, Keck PE Jr, Lazarus A. Neuroleptic malignant syndrome and related conditions, 2nd ed. Arlington, VA: American Psychiatric Press; 2003:1-44.
Ungvari GS (ed). Catatonia-an anthology of classical contributions. Hong Kong: Scientific Communications International; 2006.

Drug brand names

Amantadine • Symmetrel
Benztropine • Cogentin
Bromocriptine • Parlodel
Carbamazepine • Equetro, others
Chlorpromazine • Thorazine
Clozapine • Clozaril
Dantrolene • Dantrium
Haloperidol • Haldol
Levodopa/carbidopa • Sinemet
Levothyroxine • Synthroid
Lorazepam • Ativan
Memantine • Namenda
Olanzapine • Zyprexa
Perphenazine • Trilafon
Quetiapine • Seroquel
Ranitidine • Zantac
Risperidone • Risperdal
Trazodone • Desyrel
Valproic acid • Depakene
Ziprasidone • Geodon

Disclosures

Dr. Carroll is a speaker for Abbott Laboratories, AstraZeneca Pharmaceuticals, Bristol Myers-Squibb Co., Forest Pharmaceuticals, Janssen Pharmaceutica, and Pfizer.

Dr. Thomas receives grant support from Pfizer and is a speaker for Abbott Laboratories, AstraZeneca Pharmaceuticals, and Pfizer.

Dr. Tugrul is a consultant to and speaker for Bristol Myers-Squibb Co. and Eli Lilly and Co.

Dr. Jayanti reports no financial relationship with any company whose products are mentioned in this article, or with manufacturers of competing products.

Acknowledgment

The authors thank Francisco José Appiani, MD, chairman, psychiatry department, Military Hospital of Campo de Mayo, Buenos Aires, Argentina, and Vijay Jayanti, BS, medical student, The Ohio State University, Columbus, for their help with this article.