Published online Jun 22, 2015. doi: 10.5498/wjp.v5.i2.182
Peer-review started: September 28, 2014
First decision: November 19, 2014
Revised: February 12, 2015
Accepted: March 5, 2015
Article in press: March 9, 2015
Published online: June 22, 2015
Recent evidence favors the view of catatonia as an autonomous syndrome, frequently associated with mood disorders, but also observed in neurological, neurodevelopmental, physical and toxic conditions. From our systematic literature review, electroconvulsive therapy (ECT) results effective in all forms of catatonia, even after pharmacotherapy with benzodiazepines has failed. Response rate ranges from 80% to 100% and results superior to those of any other therapy in psychiatry. ECT should be considered first-line treatment in patients with malignant catatonia, neuroleptic malignant syndrome, delirious mania or severe catatonic excitement, and in general in all catatonic patients that are refractory or partially responsive to benzodiazepines. Early intervention with ECT is encouraged to avoid undue deterioration of the patient’s medical condition. Little is known about the long-term treatment outcomes following administration of ECT for catatonia. The presence of a concomitant chronic neurologic disease or extrapyramidal deficit seems to be related to ECT non-response. On the contrary, the presence of acute, severe and psychotic mood disorder is associated with good response. Severe psychotic features in responders may be related with a prominent GABAergic mediated deficit in orbitofrontal cortex, whereas non-responders may be characterized by a prevalent dopaminergic mediated extrapyramidal deficit. These observations are consistent with the hypothesis that ECT is more effective in “top-down” variant of catatonia, in which the psychomotor syndrome may be sustained by a dysregulation of the orbitofrontal cortex, than in “bottom-up” variant, in which an extrapyramidal dysregulation may be prevalent. Future research should focus on ECT response in different subtype of catatonia and on efficacy of maintenance ECT in long-term prevention of recurrent catatonia. Further research on mechanism of action of ECT in catatonia may also contribute to the development of other brain stimulation techniques.
Core tip: Catatonia is a treatable autonomous syndrome, frequently associated with mood disorders, but also observed in neurological, neurodevelopmental and toxic conditions. Electroconvulsive therapy (ECT) is effective in 80% to 100% of all forms of catatonia, even after pharmacotherapy with benzodiazepines has failed, and is considered first-line treatment in patients with neuroleptic malignant syndrome. Increasing the knowledge on the mechanism of action of ECT in catatonia may contribute to the development of other brain stimulation techniques, such as transcranial magnetic stimulation and deep brain stimulation. ECT response in different subtype of catatonia and efficacy of maintenance ECT in long-term prevention of recurrent catatonia deserve further research.