Successful Treatment Of Catatonic Syndrome In Bipolar I Disorder Adding Aripiprazole To ECT: A Case Report

Dr. Hidalgo

Dr. Diego Hidalgo

The adult psychiatric service, clinical institute of neuroscience hospital clinic, Barcelona, Spain.

 

Victoria Murphy:

My guest today is Dr. Diego Hidalgo from the adult psychiatric service, clinical institute of neuroscience hospital clinic, Barcelona, Spain.

Dr. Hidalgo, A very warm welcome to you and thank you for joining us.

Dr. Hidalgo:

Thank you very much for your kind invitation to discuss this article.

Victoria:

Today we are here to discuss a paper you authored in the European Journal of Psychiatry in 2012.

The title of your paper was ‘Successful treatment of catatonic syndrome in bipolar I disorder adding aripiprazole to ECT: A case report’

Dr. Hidalgo, what were the objectives of your study?

Dr. Hidalgo:

First of all, let me make a small introduction about the topic for the audience to have some background about it.

As you may know, Catatonic syndromes are one of the most dramatic and severe conditions in psychiatry.

However, now days we have an acceptable range of therapeutic options from benzodiazepines, to more invasive measures as Electroconvulsive Therapy.  Never less, there is a considerable percentage of cases who do not respond to these measures, some of these patients at last could even die.

The thing here is that, historically first generation antipsychotics showed a worrisome incidence of Neuroleptic malignant syndrome which share many clinical characteristics with catatonia itself although the mechanisms that underlie are not completely understood. It was pretty obvious that antipsychotics should be discontinued when there were suspicious symptoms of NMS and during the treatment of any catatonic syndrome.

However in the last years, there has been a lot of research to find the exact mechanisms of catatonic syndromes. It seems that they share a similar pattern of a complex imbalance of dopaminergic, serotoninergic, noradrenergic and cholinergic systems at basal ganglia and prefrontal cortex, although the exact mechanism remains unknown.

At the same time, new second generation antipsychotics showed a very low incidence of NMS and even some of them seems to help solve this imbalance due to their receptor profile. Among them, aripiprazole is a second generation antipsychotic which is known to be a partial agonist at dopamine D2 and serotonin type 1 (5-HT1A) receptors; antagonist at serotonin type 2 (5-HT2A) receptor; it probably also has an alpha-blocking activity. All of these properties seem suitable for treating the neurochemical misbalance that probably produces the catatonic syndromes.

So finally and answering to your question, our work is based in the use of aripiprazole in a difficult case of a catatonic syndrome.

Victoria:

How was it designed?

Dr. Hidalgo:

Basically, we described the case and after we made a short review of the few available evidence on the topic.

Victoria:

What types of patients were included? (What was the case about?)

Dr. Hidalgo:

Well, it is about a 17 years old known bipolar young man, who presented to our emergency room after the family reported a week of expansivity; altered sleep pattern and probable medication drop out, scoring at admission a Young Mania Rating Scale of 56. Intramuscular Haloperidol was administered at our emergency room. In a matter of hours the clinical status of the patient worsened including mutism, motor rigidity, stupor and fever of 38.9°C, together with a leukocitosisand elevated CPK totalizing a BushFrancis Catatonia Rating Scale of 36.  We couldn’t define exactly if this was a rapidly progressing catatonia or a Neuroleptic malignant syndrome due to antipsychotic administration.

Victoria:

How was the course of patient?

Dr. Hidalgo:

The patient started treatment with IM flunitrazepam and intravenous fluids therapy, and antipsychotic medication was stopped.  Despite the use of benzodiazepines at optimal doses and almost 4 sessions of ECT the patient did not respond to the treatment and the clinical picture seems every day worse than the other. We were obligated to consider other options  and after a brief research of the available evidence, we decided to introduce aripiprazole to the treatment.

Victoria:

What were the results?

Dr. Hidalgo:

Actually, the results were above our expectations. Within hours after introducing the aripiprazole, the patient showed a continuous progress, the decreasing the frequency of fever peaks, being able of doing autonomous basic tasks in 4 days (BFCRS: 16; 44.4{cf2c27d335602139ec9071daca508545599ba8f9ca09b366fd00e5c28736f208} improvement) and progressive normalization of laboratory values (Leukocytes and CPK).

Victoria:

Are there any limitations to the study?

Dr. Hidalgo:

Yes in fact, there are many limitations since it is only a case report. This and the fact that in this particular case we couldn’t have a medical diagnosis since there were relevant confounding factors, that is why we considered as a catatonic syndrome.  Under the worsening of clinical circumstances of the patient we had to consider this option and happily it was successful in our case.  Even though as we found out with our literature review there were a couple more successful cases in catatonia using aripiprazole. I have to mention here the work of Dr.Voros.

Victoria:

What conclusions can be drawn from these results?

Dr. Hidalgo:

I think maybe it could be an option to explore this condition but certainly this would require randomized controlled trials to confirm its effectiveness and safety. This could be very difficult methodologically because catatonic syndromes are extremely critical situations and only a small percentage of patients do not respond adequately to the usual treatment.

Victoria:

Can these results be considered conclusive?

Dr. Hidalgo:

Definitely no, we have not enough evidence yet to support the routinely use of antipsychotics in these type of cases. Never the less I think that is an interesting option to explore based on what we know of catatonia neurobiology, and since successful treatment of catatonia with atypical antipsychotics seems to outnumbered reports of atypical antipsychotics cause catatonia.

Victoria:

Dr. Hidalgo, thank you for joining us today, it has been a pleasure.

Dr. Hidalgo:

Thank you very much for having me.

 

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