Background
Catatonia is a behavioral syndrome marked by psychomotor symptoms (Fink, 2009); COVID-19 is an infectious disease that can cause respiratory failure and shock (Wang, 2020). Limitations in the ability to utilize conventional treatments for catatonia in COVID patients warrants exploration of alternative treatments.
Case
A 62-year-old female with psychiatric history of bipolar disorder was admitted to the medical service for complicated urinary tract infection. Psychiatry was consulted for suicidal ideation, psychosis, and catatonia. She demonstrated rigidity, gegenhalten, negativism, mutism, posturing, and withdrawal, and was started on lorazepam for catatonia. She showed considerable sedation with even low-dose benzodiazepines and was not eligible for electroconvulsive therapy (ECT) due to a new, inpatient diagnosis of COVID-19. We started her on memantine for off-label treatment of catatonia. Her catatonia subsequently improved and she once again was able to endorse suicidal ideation and intermittent hallucinations. She was able to walk, eat, and follow commands, and demonstrated minimal rigidity, though still showed signs of catatonia including intermittent mutism, staring, and posturing. After medical clearance, she was transferred to inpatient psychiatry for further psychiatric treatment.
Discussion
Treating COVID-19 positive patients presents various challenges. Mostly saliently is concern for the patient’s oxygen saturation and respiratory status. In general, providers try to avoid medications that can lower respiratory drive or increase sedation. Lorazepam is considered a first-line treatment for catatonia (Hawkins, 1995). Catatonic patients who demonstrate sedation from lorazepam and have COVID-19 present a difficult scenario in that the main treatment for catatonia may put the patient at risk for respiratory compromise. When ECT is not available, the use of medications that modulate other neurotransmitters has been shown to be effective in treating benzodiazepine-resistant catatonia (Carroll, 2007). For patients with COVID-19 and catatonia, such medications may be especially useful as there is less risk of respiratory depression.
Conclusion
COVID-19 positive patients with catatonia present a unique challenge. When there is concern for the respiratory status of the patient, consider using other pharmacologic agents in treating catatonia.
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