Case report: Diagnostic and therapeutic challenges of first-episode catatonia in a geriatric case of treatment-resistant depression

Multiple authors have discussed challenges in diagnosis and management of catatonia, but there are limited case studies highlighting multiple issues in both domains concurrently. We present a case of first-episode akinetic catatonia in a 63-year-old male with a history of treatment-resistant depression, to highlight multiple diagnostic and therapeutic challenges in catatonia and discuss learning points. The patient had a likely episode of transient ischemic attack (TIA) which precipitated delirium, and subsequently developed catatonia and severe hyponatremia. The cause behind his acute catatonia was unclear. Catatonic symptoms did not improve with benzodiazepines, while side effects of oversedation and ongoing delirium limited further uptitration of benzodiazepines. Electroconvulsive therapy was also not initiated in view of vascular risks with the recent TIA. The patient's catatonia subsequently resolved spontaneously with treatment of his medical conditions. This case highlights the complexity behind identifying etiologies of catatonia with the interplay of multiple medical conditions on the background of an affective disorder and ongoing delirium. It also illustrates therapeutic challenges in the context of unresponsiveness to benzodiazepines, presence of concomitant delirium and contraindications to initiating electroconvulsive therapy. We discuss learning points in reference to latest guidelines in management of catatonia by the British Association of Psychopharmacology (BAP), and review related literature. We discuss etiologies of catatonia, the relationship between catatonia and delirium, and offer recommendations in the face of therapeutic challenges discussed. There is a need for further research and clarification of guidelines in regard to contraindications to ECT and management of catatonia with ongoing delirium.