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

Patient: Female, 63-year-old Final Diagnosis: Schizoaffective disorder Symptoms: Catatonia • depression Clinical Procedure: — Specialty: Psychiatry OBJECTIVE: Unusual clinical course 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.