Clozapine responsive catatonia: A series of five cases
A 25-year-old female, Hindu patient from lower socio-economic class, educated upto class sixth, home maker, presented with history of mutism, staring look, rigidity, waxy flexibility and posturing for last seven days. We diagnosed her as a case of catatonia due to unknown cause. All the patients did not have any history of convulsion, seizure, head injury, high fever, dog bite or any other feature suggesting organicity. None was on any treatment prior to admission.\nKeeping aside the primary psychiatric diagnosis all the patients were given an uncommon treatment protocol to treat catatonic symptoms first. The protocol was as given below:\nAdmission in psychiatry ward Investigations Clinical-pulse, blood pressure (BP), temperature, hydration status, neurological examination, Kayser Fleischer (KF) ring Laboratory-Hemoglobin (Hb), total leucocyte count (TLC), differential leucocytes count (DLC), urea, creatinine, fasting blood sugar (FBS), liver function test (LFT), Na+, K+, urine routine and microscopy, X-ray chest, electrocardiogram (ECG), magnetic resonance imaging (MRI) brain, creatinine phosphokinase (CPK) Psychological-Busch Francis Catatonia rating scale (BFCRS). *All the above mentioned investigation reports were non-contributory for all five patients except BFCRS scores which were 30, 32, 29, 24, 22, respectively for the above mentioned patients during admission. Treatment IV Lorazepam up to 12 mg/day in divided doses starting from 3 mg/day in divided dose If not controlled by lorazepam in next 5-7 days they were given ECT (bipolar) in thrice weekly schedule for at least five ECT If not controlled by ECT they were given upto 15 mg/day of IM or mouth dissolving olanzapine for atleast two weeks Depending on the primary psychiatric diagnosis Case 2 received fluoxetine up to 40 mg/day from beginning, Case 3 received venlafaxine up to 225 mg/day after ECT failed to improve the patient and still the patient is taking venlafaxine When not controlled by the above regimen clozapine in a gradually titrating dose upto 300 mg/day with proper hematological monitoring was instituted either alone or with SNRI in the third case or SSRI in second case.\nAll the five patients responded either completely (Case 5 and 4) or partially (Case 1, 2, and 3) to clozapine in next 2-4 weeks. The BFCRS score came down to 5, 4, and 8 respectively for the first three cases. The first case was lost to follow up. The second case improved completely in next two follow up and was completely alright in third follow up as also Case 4 and 5. The third case maintained a near complete recovery with BFCRS score four in third follow up. Clozapine was tapered off in Case 4 and 5 after one month time and still they maintained well. None developed any serious side effect except transitory tachycardia in Case 1, 3, and 4 which resolved after few days.