Zolpidem in Treatment of Refractory Catatonia
Introduction: Catatonic Disorder Due to Another Medical Condition is described as a behavioral syndrome characterized by disruption in normal movement, generally associated with many psychiatric illnesses. DSM-5 criteria requires the patient to present with symptoms dominated by three or more of the following: stupor, catalepsy, waxy flexibility, mutism, negativism, posturing, mannerism, stereotypy, agitation, grimacing, echolalia and echopraxia. The following report demonstrates a case of stuporous refractory catatonia that ultimately responds to a trial of zolpidem. Increasingly more cases are demonstrating use of zolpidem as a promising therapeutic alternative to lorazepam and ECT. Case Description: A 59 y.o. Caucasian male was admitted for resistant catatonia and worsening depression since the passing of his wife 2 months prior. Patient presented primarily with stupor, mutism, and negativism for the last 1 week. The rest of the physical exam and labs on admission were within normal limits. Intramuscular and oral lorazepam resulted only in transient responsiveness, with symptoms being worse in the morning. Repeated trials of lorazepam and amantadine failed to provide results. On day 19, we began a trial of zolpidem at bedtime in addition to daily lorazepam, leading to resolution of the catatonic symptoms. This allowed us to better treat his underlying mood disorder and taper him off of the lorazepam, discharging him on only quetiapine for his mood and zolpidem for long-term treatment of his benzodiazepine-refractory catatonia. Discussion: Traditionally, catatonia has been treated with lorazepam and electroconvulsive therapy (ECT). Recently, catatonia has been treated with zolpidem, a GABA A-alpha-1 subunit agonist, which results in increased chloride conductance, neuronal hyperpolarization, inhibition of the action potential, and a decrease in neuronal excitability leading to sedative and hypnotic effects. Initially, lorazepam was trialed for this patient. While we did see fleeting responses in our patient after oral benzodiazepines, response was only temporary and patient reverted to his catatonic state. Much of the treatment focused on treating the underlying mood. Likely, the short-acting nature of lorazepam, last dose given at night, was the reason for the patient's symptoms presenting worst in the morning. After all other therapies failed, patient was trialed on zolpidem which helped with nighttime sleep and catatonia. Conclusion: While benzodiazepines continue to be the mainstay in short-term treatment, zolpidem may prove to be an effective adjunct while treating the underlying mood or thought disorder, a more permanent solution.