Moving to accelerated protocols of tDCS in schizophrenic catatonia: A case report

This is a case report of a 74-year-old woman with catatonic schizophrenia who was treated with transcranial Direct Current Stimulation (tDCS) in place of electroconvulsive therapy (ECT) during the Covid-19 pandemic that impacted access to ECT facilities. In 2021, the exceptional number of patients infected with SARS-Cov-2 led the French public hospital system to adjust its organization, temporarily redirecting anesthetists from ECT departments to ICUs. Our patient, who was hospitalized via the emergency department, presented schizophrenia with catatonic features. Due to the pandemic, ECT, which is considered the gold standard treatment for this condition, was not available. Therefore, tDCS, a neuromodulation technique that doesn't require general anesthesia, was recommended for this patient, and was delivered at the relatively (compared to standard protocols) accelerated rate of five sessions a day, five days a week. This protocol was chosen as accelerated rTMS had been shown to be effective against depression in recent trials (Cole et al. 2021), and one study had also reported this exact protocol as effective and harmless for a patient with schizophrenia (Mondino et al. 2021). The Bush-Francis Catatonia Rating Scale (BFCRS) was used to evaluate the severity of the catatonia. After 49 sessions, the clinical response was meaningful, with a BFCRS score of 16, compared to 36 at baseline. We then moved to five sessions a day, three days a week, and then two days a week. After 80 sessions, we noted the complete disappearance of catatonia (BFCRS = 6). This case provides evidence for the feasibility and tolerability of accelerated tDCS for patients with catatonia. Accelerated tDCS represents a potential alternative to ECT in the treatment of catatonia, and needs further randomized clinical studies to confirm its efficacy. Research Category and Technology and Methods Clinical Research: 9. Transcranial Direct Current Stimulation (tDCS) Keywords: tdcs, catatonia, covid-19, ECTCopyright © 2023

Effectiveness of electroconvulsive therapy in acute management of delirious mania in COVID-19 positive woman in second trimester pregnancy.

Delirious mania has been described as a state of acute excitement, fluctuating sensorium, affective and catatonic symptoms. Electroconvulsive therapy (ECT) despite being an effective treatment modality in such cases, has been under-utilised during pregnancy, mainly due to safety concerns. Here, we report the effectiveness of ECT in acute management of delirious mania in a 24 weeks pregnant woman who also tested COVID-19 positive during hospitalisation. Patient presented with three weeks history of acute manic excitement with period of altered sensorium and catatonic symptoms with no response to trials of two antipsychotic agents. After organic causes ruled out, patient was planned for ECT while ongoing antipsychotic was continued. After the first ECT session, patient tested positive for COVID-19, though asymptomatic and had to be shifted to COVID-19 isolation facility. Complete resolution of psychiatric symptoms occurred after fifth ECT. All five ECT sessions, including those in COVID-19 isolation facility were carried out under supervision of a multidisciplinary team. None of the ECT sessions had any major adverse event. Symptom remission sustained even following ECT discontinuation. No neonatal or maternal adverse effects observed after an uneventful delivery at 35 weeks. Both mother and child continued to maintain well in follow-up period of one year on oral olanzapine. In this unusual concurrent presentation of mania, delirium and catatonic symptoms during second trimester pregnancy, we highlighted the effectiveness and safety of ECT as a viable treatment modality. Additionally, management challenges posed by patient testing COVID-19 positive and then, administering ECT in COVID-19 isolation facility using personal protective equipment by multidisciplinary team has been highlighted.

Treatment of Catatonia with Asenapine in a Patient with Schizotypal Personality Disorder, Psychotic Depression and Septic Shock from SARSCoV- 2 - A Case Report.

INTRODUCTION: Catatonia is a psychomotor syndrome that presents with severe symptoms which can lead to dangerous and lethal conditions if not diagnosed and treated properly. SARS-- CoV-2 is a positive-sense single-stranded RNA virus that can occur in severe cases with acute pneumonia, ARDS, sepsis and septic shock. In these cases, ICU admission is necessary. CASE SUMMARY: A 59-year-old Caucasian man with septic shock and bilateral interstitial pneumonia from SARS-CoV-2 and schizotypal personality disorder presented with catatonic behaviour manifested by soporous state, response to intense painful stimuli with the opening of the eyes, execution of simple verbal commands, maintenance of the same position, catalepsy, immobility, rigidity and mutism. At the same time, there were symptoms of septic shock and catatonic symptoms, causing greater difficulty in the correct formulation of the diagnosis. During the course of his hospitalization, he was treated with asenapine 20 mg/day. The catatonia responded rapidly and significantly to the asenapine. DISCUSSION: To date, the pathophysiology of catatonia is unclear, and few guidelines are available for the treatment of catatonia. In the literature, studies have reported the efficacy of benzodiazepines such as lorazepam and diazepam, GABAA agonists such as zolpidem, NMDA receptor antagonists such as memantine, antidepressant SSRIs such as fluoxetine and paroxetine, and antipsychotics such as olanzapine, clozapine and aripiprazole. We demonstrate that the antipsychotic asenapine is also effective in treating catatonic symptoms in psychiatric disorders. CONCLUSION: Asenapine produced a rapid and significant reduction in catatonic symptoms in our patient with schizotypal personality disorder.

Unexpected cancellation on a catatonic patient's electroconvulsive therapy due to the coronavirus pandemic.

We report a case of a 39-year-old woman with a psychiatric history of schizoaffective disorder with catatonia, dependent personality disorder and substance use disorder whose symptoms have been very difficult to control. During her most recent inpatient admission, she was treated with electroconvulsive therapy (ECT) for catatonia. Our treatment team was hopeful that ECT was making a difference for this patient. However, she was only able to receive two sessions of treatment due to new hospital protocols related to the coronavirus pandemic. Although the patient was not suspected to have the coronavirus, she could no longer undergo ventilation with a bag and mask during the procedure. Bag-mask ventilation is known to aerosolise the coronavirus and other diseases and potentially put healthcare workers at risk. Although orotracheal intubation also aerosolises the coronavirus, this was the only means of airway management still allowed by anaesthesia providers at this time. Our psychiatry team estimated that the risks of intubation outweighed the benefits of treatment, and ECT was cancelled. Without additional ECT treatments, the patient again decompensated for several weeks before being stabilised on clozapine, haloperidol and lorazepam. Although she eventually had a positive treatment outcome, her hospital course was likely prolonged due to unforeseen events related to the novel coronavirus. We feel that the current medical climate is unprecedented and is interfering with necessary psychiatric treatment in an unanticipated way. Anaesthesiologists will need to be flexible while working with psychiatrists and identify safe ways to provide this necessary psychiatric treatment for patients.