Dramatic and Rapid Resolution of Both Psychosis and Neuroleptic-Related Catatonia With Zolpidem in a Patient With Systemic Lupus Erythematosus

Catatonia induced by antipsychotics in an adolescent male patient with systemic lupus erythematosus: A case report

BACKGROUND

Systemic lupus erythematosus (SLE) can affect multiple organs or systems. The involvement of the central nervous system can result in the manifestation of epilepsy, an acute confusional state, and other rare neuropsychiatric presentations, such as catatonia.

CASE SUMMARY

We present a case of an adolescent male patient with first-onset SLE who presented with neuropsychiatric symptoms including epilepsy and delirium. The initial utilization of olanzapine to alleviate symptoms of agitation precipitated the emergence of catatonia, which was mitigated by discontinuing olanzapine and supplementing with lorazepam. In this case, whether the catatonia was secondary to the utilization of antipsychotics or to an organic disease is a question that warrants differential diagnosis.

CONCLUSION

Multidisciplinary collaborative management is the cornerstone for the successful management of severe cases of SLE.

Zolpidem for the Management of Catatonia: A Systematic Review

BACKGROUND

Catatonia is a psychomotor syndrome associated with neurotransmitter disturbances, common in both psychiatric and medical settings. Hypoactivity of the GABAA receptor is one of the predominant theories behind the pathophysiology of catatonia, affecting both motor functioning and emotional regulation. Benzodiazepines such as lorazepam are considered the first-line treatment for catatonia. However, up to 27% of catatonia cases fail to respond to benzodiazepines alone. Zolpidem, which can be used as a challenge, monotherapy, or augmentation agent, serves as a promising pharmacological agent for catatonia due to its unique pharmacodynamic and pharmacokinetic profile.

OBJECTIVE

We sought to systematically examine the evidence behind zolpidem's use among adult patients to understand its clinical utility in the management of catatonia against prevailing treatments such as lorazepam and electroconvulsive therapy.

METHODS

We conducted a systematic review using search terms related to zolpidem and catatonia in PubMed, EMBASE, and Web of Science. We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and identified 29 studies, including case studies and case series that met inclusion criteria.

RESULTS

We reviewed 35 cases in which zolpidem was used for catatonia management (age: mean = 51.5 ± 21.0 standard deviation years; 68.6% female; Bush Francis Catatonia Rating Scale: mean = 22.2 ± 9.0 standard deviation). Proportions of positive responses for zolpidem on catatonia varied by treatment approach: 91% as a challenge agent (n = 10), 100% as a first-line monotherapy agent (n = 3), 57% as a first-line combination therapy agent (n = 4), 70% as a second-line monotherapy agent (n = 7), and 100% as a second-line augmentation agent (n = 4). In total, 28 out of the 35 reported cases of catatonia (80%) responded positively to zolpidem.

CONCLUSIONS

An 80% positive response rate for zolpidem in lysing catatonia is encouraging but may be an overestimate due to reporting bias of case-level data. Results may be explained by zolpidem's selectivity for the α1 subunit of the GABAA receptor. Thus, zolpidem may be an underutilized catatonia treatment and prove useful in situations when benzodiazepines fail or when electroconvulsive therapy access is limited. Given that current literature on the use of zolpidem for catatonia is limited to case reports, more robust research in this area is warranted.

The Use of Zolpidem in Catatonia: A Case Report

Catatonia is a complex neuropsychiatric syndrome characterised by abnormal psychomotor disturbance, which poses a diagnostic and treatment challenge to clinicians. It is a life-threatening condition in its severe form, termed malignant and characterised by hyperthermia and autonomic disturbances. Early recognition and treatment are important in its management. A screening instrument, such as the Bush-Francis Catatonia Rating Scale (BFCRS), can help the clinician make a prompt diagnosis. Only a few published cases describe zolpidem being used to treat this condition, with lorazepam and electroconvulsive therapy (ECT) more commonly utilised as part of established treatment protocols. We discuss a case of a 70-year-old female with treatment-resistant depression and catatonic features who was successfully managed with zolpidem. This report highlights the role and efficacy of zolpidem in the clinical management of catatonia.

Evidence-based consensus guidelines for the management of catatonia: Recommendations from the British Association for Psychopharmacology

The British Association for Psychopharmacology developed an evidence-based consensus guideline on the management of catatonia. A group of international experts from a wide range of disciplines was assembled. Evidence was gathered from existing systematic reviews and the primary literature. Recommendations were made on the basis of this evidence and were graded in terms of their strength. The guideline initially covers the diagnosis, aetiology, clinical features and descriptive epidemiology of catatonia. Clinical assessments, including history, physical examination and investigations are then considered. Treatment with benzodiazepines, electroconvulsive therapy and other pharmacological and neuromodulatory therapies is covered. Special regard is given to periodic catatonia, malignant catatonia, neuroleptic malignant syndrome and antipsychotic-induced catatonia. There is attention to the needs of particular groups, namely children and adolescents, older adults, women in the perinatal period, people with autism spectrum disorder and those with certain medical conditions. Clinical trials were uncommon, and the recommendations in this guideline are mainly informed by small observational studies, case series and case reports, which highlights the need for randomised controlled trials and prospective cohort studies in this area.