Oral and Intranasal Ketamine Use in Treatment-Resistant Catatonia: A Clinical Case Report

Abstract

BACKGROUND Benzodiazepines and electroconvulsive therapy (ECT) are standard treatment options for catatonia, a life-threatening psychomotor syndrome in people with serious mental illness. The purpose of this study was to discuss the use of ketamine in treatment-resistant catatonia, which has not been established in current literature. CASE REPORT A 63-year-old woman with schizoaffective disorder and many previous psychiatric hospitalizations was initially admitted to a psychiatric unit for severe catatonic condition, including mutism, psychomotor retardation, poor intake, and significant weight loss. She had historically failed many ECT treatments and a course of transcranial magnetic stimulation. She scored 12 on the Bush-Francis Catatonia Rating Scale. After she had no response to lorazepam or ECT, she was started on sublingual ketamine, 50 mg twice a week. She showed significant improvement and her Bush-Francis Catatonia Rating Scale score decreased steadily. She was successfully discharged home but had a quick readmission after missing a dose of ketamine. After it was resumed, she progressively improved and was again discharged home. She continued taking sublingual ketamine, until her insurance approved esketamine nasal spray. Due to a change in insurance approval, later she was switched to a combination of esketamine and sublingual ketamine. She steadily resumed her baseline activities and remained clinically stable. She did not require acute hospitalization in the months that followed. CONCLUSIONS This case highlights a potential use of sublingual ketamine and esketamine nasal spray as a treatment option in patients with chronic catatonia when other treatment choices fail to be effective.

Figure 1.

Timeline of Bush Francis Catatonia Rating Scale (BFCRS) score change with ketamine treatment. The initial drop in score on 12/6/21 followed a 2-mg i.v. lorazepam challenge, after which, scheduled lorazepam was initiated at 1.5 mg 3 times a day. The BFCRS is a tool developed to facilitate the diagnosis and treatment of catatonia. It consists of 23 items, such as immobility/stupor, mutism, posturing, rigidity, withdrawal, rated on a 1 to 3-point scale. The first 14 items can be administered as a screening instrument, known as the Bush Francis Catatonia Screening Instrument, rated on the presence or absence of symptoms [4].