Malignant Catatonia Treatment: Case Series Review From Germany
Out on PubMed, from investigators in Germany, is this paper:
Malignant Catatonia: severity, treatment and outcome - a systematic case series analysis.
World J Biol Psychiatry. 2021 May 5:1-28. doi: 10.1080/15622975.2021.1925153. Online ahead of print.PMID: 33949287
The abstract is copied below:
Malignant catatonia (MC) is a rare, yet potentially life-threatening neuropsychiatric condition. Evidence on its therapy is weak, treatment recommendations are scarce and predominantly unprecise. The aim of this study was to compare the effectiveness of different MC treatment approaches regarding outcome and severity of MC. We conducted systematic searches for MC case reports in biomedical databases and the psychiatric archive of University Hospital Ulm. 117 cases were included. Treatments were compared considering MC severity and temporal aspects. Treatment had a significant influence on outcome: treatment with both benzodiazepines and electroconvulsive therapy (ECT) entailed the most favorable, purely supportive therapy the least favorable outcome. Earlier application of benzodiazepines was significantly associated with a favorable outcome. A classification of MC severity was developed. Patients with severe MC were significantly more often subject to intensive care treatment and had a 78% higher risk of dying than in moderate MC. This is the first study to introduce a severity classification for MC, and the largest to compare outcomes of MC treatments with clear distinction from neuroleptic malignant syndrome (NMS). Preferable MC treatment should include early initiation of benzodiazepines and ECT. MC severity could serve as a prognostic instrument.Keywords: benzodiazepines; catatonia; electroconvulsive therapy; mortality; therapeutics.
And from the text:
Results
The literature search produced 2,522 results. A total of 117 MC case reports were included in
this research, of which 116 derived from 88 publications included after the screening process
of the literature search (Figure 1 shows the flow-chart), and one case from the local search at
the University Hospital Ulm. While data were collected as extensive as possible, some
publications did not contain all the information requested.
...Of all 117 patients with MC, n = 100 (85.5%) survived, with n = 70 (59.8%) reaching full
remission and n = 28 (23.9%) partial remission. 17 patients (14.5%) died in the course of MC.
Survival rates continuously rose from 37,5% (3/8) before 1960 to 96,4% (27/28) in the 1990s
and recently amounted to 95,1% (39/41) between 2010 and 2019.
No deaths (0.0%) and the highest rate of cases with full remission (76.7%, n=33) was found
in patients treated with both benzodiazepines and ECT (‘BZD + ECT’), whereas highest death
rate (72.7%, n=8) and lowest rate of full remission (18.2%, n=2) was found in patients where treatment didn’t exceed supportive therapy (‘ST’).
Discussion
The available data of 117 cases of MC was analyzed, focusing on treatment and outcome. The
mortality rates diverged, in part significantly, between different treatment groups. The lowest
mortality rates were found in patients treated with both benzodiazepines and ECT, and highest
in antipsychotics and supportive therapy groups. Severe MC implied significantly higher rates
of intensive care treatment and mortality than moderate MC. While in moderate MC,
benzodiazepine monotherapy and its combination with ECT both entailed a 100% survival
rate (14/14 and 31/31 respectively), in severe MC this was only the case in the group treated
with both benzodiazepines and ECT (14/14). Early benzodiazepine treatment was related to a
more favorable outcome, with significantly earlier treatment initiation in patients reaching full
remission. Apart from treatment, the absence of a prodromal phase, severe MC and the
occurrence of complications were associated with a higher risk of mortality.
The introduction of a classification of MC severity is new to specialist literature. Patients with
severe MC had a higher mortality rate, a significantly lower rate of full remission and higher
rate of intensive care treatment. The classification is based on three clinical parameters, it thus
can be applied quickly and could prove useful in the context of clinical prognosis assessment.
Our results suggest equal outcomes for benzodiazepine monotherapy and its combination with
ECT in moderate MC, as opposed to superior outcome under combination therapy in severe
MC. However, further research is needed to evaluate effectiveness of individual treatment
approaches in different degrees of severity.
This review article shows that certainty regarding optimal treatment of MC is not yet
achieved. What can be concluded from our findings, however, is that the most favorable
outcome in cases of MC is to be expected under use of both benzodiazepines and ECT.
Antipsychotics should have no place in MC treatment. For the first time, a severity
classification of MC was introduced into published literature, potentially being able to serve
as a future prognostic instrument. Further research on causal treatment of MC, especially
taking into account its severity degrees, is necessary.
This is an important, well-conducted and presented literature review (plus one new case added); it is a significant contribution to the catatonia literature, reminding us that malignant catatonia (MC), formerly called "lethal catatonia," can be lethal. (The authors describe the course of MC as "foudroyant," French for "overwhelming, sudden and violent, devastating, as if struck by lightning...")
Innovations of this review include the careful exclusion of NMS cases, and the severity classification. Take home messages are clear: prognosis of more severe illness is worse, benzos and ECT are effective treatments, early intervention is needed, and neuroleptics are contraindicated.
This is a must-read in full, ~20 minutes.
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