(036) Valproate as an Effective Alternative to Lorazepam in Malignant Catatonia: A Case Report and Literature Review

Abstract:

Background:
Catatonia presents a significant treatment challenge in psychiatric practice, with traditional treatments such as benzodiazepines and Electroconvulsive Therapy (ECT) not always effective. The exploration of Valproate as an alternative treatment is driven by the need for effective second-line treatments, given its documented successes in several case reports.

Method:
We present a case of catatonia unresponsive to Lorazepam, successfully treated with Valproate, and review literature to explore Valproate's role in treating catatonia. The search was performed using Pubmed and Google Scholar Databases, with search terms “Catatonia” AND (“Depakote” OR “Valproate” OR “Valproic Acid”).

Case:
A 19-year-old Hispanic male who was admitted to our hospital with severe, sudden depression and bizarre behavior. Initially, during a prior hospitalization, the patient's catatonia, as assessed by the Bush-Francis Catatonia Rating Scale (BFCRS), was scored at 16. Despite multiple treatments with both intramuscular and oral Lorazepam, his BFCRS showed minimal improvement, decreasing by only two points. Upon current admission, his condition had escalated to malignant catatonia, evidenced by a BFCRS of 19, accompanied by tachycardia and diaphoresis. The patient was initially given a total of seven doses of intramuscular and oral Lorazepam (total 18mg), with a minimal (2-point) reduction in BFCRS. As ECT was unavailable, Lorazepam was discontinued in favor of a trial of oral Valproate 500mg twice daily, and his catatonia subsided after several days (serum level of 60.8). The patient was started on oral Risperidone 0.5mg once at night, titrated up to 3mg twice daily, and he eventually returned to baseline.

Discussion:
Literature review showed nine unique case reports where Valproate was used for catatonia, including cases resistant to traditional treatments (Krüger & Bräunig, 2001; Maier et al., 2021). These reports suggest Valproate's success may be attributed to its influence on GABAergic pathways (Mahmoudi et al., 2017; Lewis et al., 2009), indicating a neurochemical mechanism at play. Furthermore, the literature shows the importance of identifying underlying conditions that may contribute to catatonic symptoms, such as mood disorders or nutritional deficiencies, where Valproate's mood-stabilizing properties could offer dual benefits. Some case studies demonstrate Valproate's utility in acute treatment and its potential for preventing future catatonic episodes, further supported by the accounts of Yoshida et al. (2005) regarding its prophylactic use.

Conclusion:
This collective evidence positions Valproate as a viable, perhaps underrecognized, option in catatonia management, advocating for its consideration by clinicians in complex cases where standard treatments fail.

References:
1. Krüger, S., (2001). Intravenous valproic acid in the treatment of severe catatonia. Journal of neuropsychiatry and clinical neurosciences, 13(2), 303–304
2. Maier, J., Rapport, D.(2021). Oral Valproate Sodium as an Alternative to Benzodiazepine in the Treatment of Catatonia
3. Mahmoudi, M., (2017). A Case of Recurrent Hypersomnia With Autonomic Dysfunction. Journal of clinical sleep medicine: JCSM 13(7), 923–924
4. Lewis, A. L., Pelic, C., (2009). Malignant catatonia in a patient with bipolar disorder, Journal of psychiatric practice, 15(5), 415–422
5. Yoshida, I., Monji, A, (2005). Prophylactic effect of valproate in the treatment for siblings with catatonia. Journal of clinical psychopharmacology, 25(5), 504–505

Presentation Eligibility: Not previously published or presented

Diversity, Equity, and Inclusion: In our study on Valproate's role in treating malignant catatonia, we prioritize DEI, focusing on a Hispanic patient from a low-income Bronx community, highlighting healthcare equity. Our diverse team, with South Korean and South Asian backgrounds, emphasizes culturally sensitive care for marginalized groups. This case illustrates the necessity for accessible and inclusive treatment methods, advocating for comprehensive healthcare practices that accommodate diverse patient needs. By showcasing a non-traditional treatment's success in a community hospital setting, our work underscores the importance of diversity in clinical research and treatment planning, aiming to enhance psychiatric care for all, especially in underserved populations.