Pharmacopsychiatry 2024; 57(01): 13-20
DOI: 10.1055/a-2195-1499
Original Paper

The Effect of Electroconvulsive Therapy on Specific Catatonia Symptoms and Predictors of Late Response

Sigrid Breit
1   University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
2   Translational Research Center, University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
Agnes Meyer
1   University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
Wolfgang Schmitt
1   University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
Tobias Bracht
1   University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
2   Translational Research Center, University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
Sebastian Walther
1   University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
2   Translational Research Center, University Hospital of Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
› Author Affiliations


Introduction Electroconvulsive therapy (ECT) is known to be effective in the treatment of catatonia, reaching response rates of about 80 to 100%. It is indicated in cases of treatment resistance to benzodiazepines and in life-threatening conditions such as malignant catatonia. Beneficial effects on specific symptoms or predictors of response are less clear. The objective of this retrospective study is to examine the ECT effect on specific catatonia symptoms in the acute phase of the illness and to identify predictors of response.

Methods A retrospective study examined data from 20 patients with catatonia, 18 associated with schizophrenia and 2 with bipolar disorder, who underwent ECT from 2008 to 2021. Ten subjects had more than one ECT-series, resulting in a total of 31 ECT-series. Catatonia symptom severity was assessed with the Bush Francis Catatonia Rating Scale (BFCRS).

Results ECT yielded excellent response. Nineteen of 20 patients and 30 of 31 ECT-series achieved response. The mean number of ECT sessions to response was 4.2. Response to ECT was more pronounced for motor inhibition symptoms such as stupor and mutism, while echophenomena, dyskinesia, stereotypy and perseveration responded less well. A predictor of late response was the presence of grasp reflex.

Discussion The present study corroborates the high and rapid effectiveness of ECT in the treatment of catatonia. Focus on single catatonia signs may help to identify those who are most likely to achieve remission quickly, as well as those who might need longer ECT-series.

Publication History

Received: 31 May 2023
Received: 05 October 2023

Accepted: 11 October 2023

Article published online:
23 November 2023

© 2023. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

  • References

  • 1 Tandon R, Heckers S, Bustillo J. et al. Catatonia in DSM-5. Schizophr Res 2013; 150: 26-30
  • 2 Walther S, Strik W. Catatonia. CNS Spectr 2016; 21: 341-348
  • 3 Solmi M, Pigato GG, Roiter B. et al. Prevalence of catatonia and its moderators in clinical samples: Results from a meta-analysis and meta-regression analysis. Schizophr Bull 2018; 44: 1133-1150
  • 4 Rogers JP, Pollak TA, Begum N. et al. Catatonia: demographic, clinical and laboratory associations. Psychol Med 2021; 53: 1-11
  • 5 Rogers JP, Oldham MA, Fricchione G. et al. Evidence-based consensus guidelines for the management of catatonia: Recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2023; 37: 327-369
  • 6 Walther S, Stegmayer K, Wilson JE. et al. Structure and neural mechanisms of catatonia. Lancet Psychiatry 2019; 6: 610-619
  • 7 Heckers S, Walther S. Caring for the patient with catatonia. JAMA Psychiatry 2021; 78: 560-561
  • 8 Bush G, Fink M, Petrides G. et al. I. Rating scale and standardized examination. Acta Psychiatr Scand 1996; 93: 129-136
  • 9 Wortzel JR, Maeng DD, Francis A. et al. Prevalent gaps in understanding the features of catatonia among psychiatrists, psychiatry trainees, and medical students. J Clin Psychiatry 2021; 82 21m14025
  • 10 Bush G, Fink M, Petrides G. et al. Catatonia. II. Treatment with lorazepam and electroconvulsive therapy. Acta Psychiatr Scand 1996; 93: 137-143
  • 11 Unal A, Altindag A, Demir B. et al. The use of lorazepam and electroconvulsive therapy in the treatment of catatonia: Treatment characteristics and outcomes in 60 patients. J ECT 2017; 33: 290-293
  • 12 Hirjak D, Fricchione G, Wolf RC. et al. Lorazepam in catatonia – Past, present and future of a clinical success story. Schizophr Res. 2023 S0920-9964(23)00057-9.
  • 13 Pelzer AC, van der Heijden FM, den Boer E. Systematic review of catatonia treatment. Neuropsychiatr Dis Treat 2018; 14: 317-326
  • 14 Suchandra HH, Reddi VSK, Aandi Subramaniyam B. et al. Revisiting lorazepam challenge test: Clinical response with dose variations and utility for catatonia in a psychiatric emergency setting. Aust N Z J Psychiatry 2021; 55: 993-1004
  • 15 Seethalakshmi R, Dhavale S, Suggu K. et al. Catatonic syndrome: Importance of detection and treatment with lorazepam. Ann Clin Psychiatry 2008; 20: 5-8
  • 16 Girish K, Gill NS. Electroconvulsive therapy in lorazepam non-responsive catatonia. Indian J Psychiatry 2003; 45: 21-25
  • 17 England ML, Ongur D, Konopaske GT. et al. Catatonia in psychotic patients: Clinical features and treatment response. J Neuropsychiatry Clin Neurosci 2011; 23: 223-226
  • 18 Ungvari GS, Chiu HF, Chow LY. et al. Lorazepam for chronic catatonia: A randomized, double-blind, placebo-controlled cross-over study. Psychopharmacology (Berl) 1999; 142: 393-398
  • 19 Luchini F, Medda P, Mariani MG. et al. Electroconvulsive therapy in catatonic patients: Efficacy and predictors of response. World J Psychiatry 2015; 5: 182-192
  • 20 Cronemeyer M, Schonfeldt-Lecuona C, Gahr M. et al. Malignant catatonia: Severity, treatment and outcome – a systematic case series analysis. World J Biol Psychiatry 2022; 23: 78-86
  • 21 Rohland BM, Carroll BT, Jacoby RG. ECT in the treatment of the catatonic syndrome. J Affect Disord 1993; 29: 255-261
  • 22 Hatta K, Miyakawa K, Ota T. et al. Maximal response to electroconvulsive therapy for the treatment of catatonic symptoms. J ECT 2007; 23: 233-235
  • 23 Raveendranathan D, Narayanaswamy JC, Reddi SV. Response rate of catatonia to electroconvulsive therapy and its clinical correlates. Eur Arch Psychiatry Clin Neurosci 2012; 262: 425-430
  • 24 Leroy A, Naudet F, Vaiva G. et al. Is electroconvulsive therapy an evidence-based treatment for catatonia? A systematic review and meta-analysis. Eur Arch Psychiatry Clin Neurosci 2018; 268: 675-687
  • 25 van Waarde JA, Tuerlings JH, Verwey B. et al. Electroconvulsive therapy for catatonia: Treatment characteristics and outcomes in 27 patients. J ECT 2010; 26: 248-252
  • 26 Tripodi B, Barbuti M, Novi M. et al. Clinical features and predictors of non-response in severe catatonic patients treated with electroconvulsive therapy. Int J Psychiatry Clin Pract 2021; 25: 299-306
  • 27 Northoff G, Koch A, Wenke J. et al. Catatonia as a psychomotor syndrome: A rating scale and extrapyramidal motor symptoms. Mov Disord 1999; 14: 404-416
  • 28 Kruger S, Cooke RG, Spegg CC. et al. Relevance of the catatonic syndrome to the mixed manic episode. J Affect Disord 2003; 74: 279-285
  • 29 Taylor MA, Fink M. Catatonia in psychiatric classification: A home of its own. Am J Psychiatry 2003; 160: 1233-1241
  • 30 Sienaert P, Rooseleer J, De Fruyt J. Measuring catatonia: A systematic review of rating scales. J Affect Disord 2011; 135: 1-9
  • 31 Aandi SB, Muliyala KP, Suchandra HH. et al. Diagnosing catatonia and its dimensions: Cluster analysis and factor solution using the Bush Francis Catatonia Rating Scale (BFCRS). Asian J Psychiatr 2020; 52: 102002
  • 32 Sarkar S, Sakey S, Mathan K. et al. Assessing catatonia using four different instruments: Inter-rater reliability and prevalence in inpatient clinical population. Asian J Psychiatr 2016; 23: 27-31
  • 33 Zingela Z, Stroud L, Cronje J. et al. Assessment of catatonia and inter-rater reliability of three instruments: A descriptive study. Int J Ment Health Syst 2021; 15: 82
  • 34 Walther S, Weiss F. Catatonia through the ages – from Kahlbaum to the ICD-11. Fortschr Neurol Psychiatr 2023; 91: 52-68
  • 35 Reed GM, First MB, Kogan CS. et al. Innovations and changes in the ICD-11 classification of mental, behavioural and neurodevelopmental disorders. World Psychiatry 2019; 18: 3-19
  • 36 Sienaert P, Dhossche DM, Vancampfort D. et al. A clinical review of the treatment of catatonia. Front Psychiatry 2014; 5: 181
  • 37 Banerjee A, Sharma LN. Catatonia incidence in acute psychiatric admissions. Indian J Psychiatry 1995; 37: 35-39
  • 38 Ramdurg S, Kumar S, Kumar M. et al. Catatonia: Etiopathological diagnoses and treatment response in a tertiary care setting: A clinical study. Ind Psychiatry J 2013; 22: 32-36
  • 39 Odayar K, Eloff I, Esterhuysen W. Clinical and demographic profile of catatonic patients who received electroconvulsive therapy in a South African setting. S Afr J Psychiatr 2018; 24: 1100
  • 40 Mestre T, Lang AE. The grasp reflex: A symptom in need of treatment. Mov Disord 2010; 25: 2479-2485
  • 41 Schott JM, Rossor MN. The grasp and other primitive reflexes. J Neurol Neurosurg Psychiatry 2003; 74: 558-560
  • 42 Wilson JE, Niu K, Nicolson SE. et al. The diagnostic criteria and structure of catatonia. Schizophr Res 2015; 164: 256-262
  • 43 Suzuki K, Awata S, Matsuoka H. One-year outcome after response to ECT in middle-aged and elderly patients with intractable catatonic schizophrenia. J ECT 2004; 20: 99-106
  • 44 Suzuki K, Awata S, Takano T. et al. Continuation electroconvulsive therapy for relapse prevention in middle-aged and elderly patients with intractable catatonic schizophrenia. Psychiatry Clin Neurosci 2005; 59: 481-489
  • 45 Levy-Rueff M, Jurgens A, Loo H. et al. Maintenance electroconvulsive therapy and treatment of refractory schizophrenia. Encephale 2008; 34: 526-533
  • 46 Krepela J, Hosak L, Pachlova B. et al. Maintenance electroconvulsive therapy in schizophrenia. Psychiatr Danub 2019; 31: 62-68
  • 47 Hawkins JM, Archer KJ, Strakowski SM. et al. Somatic treatment of catatonia. Int J Psychiatry Med 1995; 25: 345-369
  • 48 Hasoglu T, Francis A, Mormando C. Electroconvulsive therapy-resistant catatonia: Case report and literature review. J Acad Consult Liaison Psychiatry 2022; 63: 607-618
  • 49 Madigand J, Lebain P, Callery G. et al. Catatonic syndrome: From detection to therapy. Encephale 2016; 42: 340-345
  • 50 Worku B, Fekadu A. Symptom profile and short term outcome of catatonia: An exploratory clinical study. BMC Psychiatry 2015; 15: 164
  • 51 Walther S, Alexaki D, Schoretsanitis G. et al. Inhibitory repetitive transcranial magnetic stimulation to treat psychomotor slowing: A transdiagnostic, mechanism-based randomized double-blind controlled trial. Schizophrenia Bulletin Open 2020; 1: 1
  • 52 World Health Organization. 2020 ICD-11: International classification of diseases (11th revision).