Catatonic Depression: Causes, Symptoms, And Recovery

Catatonic depression is a severe form of depression believed to be caused by a dysfunction of the chemicals in the brain (neurotransmitters), with several other factors also involved. Catatonia is characterized by the inability to speak or physically move, affecting all aspects of a person’s life. 

Treatment for catatonia is possible and involves medication and other therapies. However, if left untreated, it can lead to serious health complications.  

What is catatonic depression?

Catatonic depression is a group of symptoms and signs involving a lack of or complete absence of movement and communication. Catatonia is reported in approximately 10%¹ of patients with acute psychiatric illness.

Historically, catatonic depression was considered to be a subtype of schizophrenia. However, due to changes in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, it is now classified as stemming from other mental health problems, neurological disorders, and medical illnesses.

It is also believed to occur and can be diagnosed independently of any mental health or medical illness.   

Catatonia is a serious mental health condition that must be identified and diagnosed in its early stages. If not, recovery may take much longer and be harder to treat. In some cases, it can lead to life-threatening problems. 

Symptoms of catatonia

Catatonia is composed of multiple signs and symptoms, of which only three need to be present to make the diagnosis, according to the DSM-V. The DSM-V lists 12 symptoms — however, researchers² have identified and described more than 40 signs. 

The 12 symptoms include: 

1. Mutism: Minimal to no verbal response or communication (The most common symptom was observed in around 95% of patients with catatonia.).

2. Stupor: The state of being in a daze and staring (The second most common symptom was seen in around 70% of patients.).

3. Negativism: Lack of response to external stimuli and instructions

4. Immobility: Lack of movement in response to external stimuli and intrusions

5. Waxy flexibility: Retaining a posture into which the patient was placed by another person for a prolonged period.

6. Posturing: Positioning oneself in an awkward and uncomfortable posture against gravity

7. Stereotypy: Making repetitive movements or sounds

8. Catalepsy: Decreased sensitivity to pain

9. Agitation: May appear upset or irritable

10. Mannerism: Displaying odd and exaggerated actions

11. Grimacing: Maintaining a certain facial expression for a long period

12. Echolalia: Copying of another’s speech

Types of catatonic depression

There are three types of catatonia. These are: 

1. Akinetic catatonia: This is the most common and most frequently observed subtype. 

2. Excited catatonia: This is less common than Akinetic, but it is still commonly observed in patients. 

3. Malignant catatonia: This is a rare type of catatonia. Malignant catatonia is dangerous and generally appears due to a potentially lethal underlying health condition. 

Causes of catatonia

The exact cause of catatonic depression is unknown. Researchers³ have found strong evidence to suggest that the neurotransmitters glutamate, serotonin, dopamine, and GABA all play a role in catatonia. However, there are a wide variety of possible causes that contribute to catatonia. These are discussed below.  

Genetics and family history

One of the leading causes of catatonia is genetics. A study⁴ suggested that you have a 27% risk of experiencing catatonia if a direct family member has been affected by it. Having a family member suffer from depression or a mood disorder can also increase your chances of developing catatonia.  

Mental health and neurological disorders

Current or previous experiences with mental health disorders are considered a leading cause of catatonia. Bipolar disorder, obsessive-compulsive disorder, autism, post-traumatic stress disorder, major depressive disorder, Parkinson’s disease, and severe anxiety may all increase the likelihood of catatonia.  

Medical conditions

Many patients with catatonia have been found to have a medical cause rather than a psychiatric or neurological one. Medical conditions that can cause catatonia include viral, fungal, and bacterial infections, stroke, liver transplantation, autoimmune disorders, low blood sodium concentration, and brain blood clots.  

Medications

The withdrawal of certain medications, such as benzodiazepines or clozapine, can place some individuals at risk for catatonia, especially before the end of a treatment course. As these medications increase GABA activity, discontinuation may increase excitatory neurotransmission in the brain, leading to catatonia. 

Drugs and alcohol

Heavy drinking and regular illicit drug use are thought to increase a person’s chance of catatonia. Withdrawal from these substances by a heavy user can also be a contributing cause.   

Diagnosis of catatonia 

There is currently no definitive test for catatonia. Physical examination and further testing is the best way to diagnose catatonia and differentiate it from other conditions. 

A physical examination of the patient may involve: 

• Observing the patient during normal conversation to see if they repeat words or copy what the doctor says

• Performing movements to see if the patient will copy them

• Observing passive movement and posture of limbs

• Moving the patient’s limbs to see if they resist or hold the position 

• Checking for grasp reflex

• Checking vital signs

Further lab tests may be ordered to help diagnose catatonia, assess the patient’s health status, and determine if there are any underlying health conditions. 

In some cases, the doctor may require a patient suspected of having catatonic depression to have an EEG, MRI, or CT scan to screen for catatonia and other health conditions.  

Treatment and recovery for catatonic depression

Treatment will depend on how long you have had catatonic depression, your overall health condition, and if you have any underlying mental, neurological, or medical conditions. 

The first line of treatment for catatonia is medication, and if that is ineffective or the patient has severe catatonia, then electroconvulsive therapy may be considered. 

Medication

Benzodiazepines are the initial medication used to treat catatonia, no matter the type of catatonia or if the patient has underlying health conditions. Studies have shown a positive response rate of up to 80% following the administration of benzodiazepines. 

Electroconvulsive therapy

If benzodiazepines are ineffective or unsuitable, then ECT may be offered. ECT is a safe treatment and has a high success rate. It involves electrical brain stimulation under anesthesia so the patient does not feel any pain. As ECT is an invasive procedure, it is used as a last resort.  

Caring and supporting a loved one who has catatonic depression

Steps you can take to help a loved one when they are unwell: 

• If you suspect your loved one has catatonia, support them in seeing a doctor or healthcare professional. 

• Inform and educate yourself about the diagnosis, symptoms, and treatment of catatonia. This will help you better understand what your loved one is going through. 

• Support your loved one with their treatment plan and encourage them to stick to it by providing positive feedback and words of encouragement.  

How long does catatonic depression last?

This will be different for every individual. In most cases, researchers have found that catatonic depression episodes are acute, meaning they appear suddenly and only last for a few days or weeks. However, some catatonic episodes can be chronic, lasting for months or even years. 

Generally, if catatonia is diagnosed and treated quickly, then catatonia episodes can be short-lived, and relapses are less likely. However, catatonic episodes are expected to last longer if left untreated, and relapse is highly likely.  

Complications

The symptoms of catatonia can lead to serious health complications and, in some cases, can be life-threatening if left untreated. As catatonia affects mobility and movement, this gives rise to several complications:

• Refusal or inability to eat and drink, which may lead to dehydration and malnutrition 

• Deep vein thrombosis

• Pressure ulcers 

• Pneumonia 

• Pulmonary embolism

• Infections

• Muscle wastage

• Self-harm or suicidal thoughts

These complications highlight the importance of recognizing catatonia and quickly initiating treatment.  

The lowdown

Catatonia is a cluster of symptoms and signs that can be caused by several different factors, including current or recent mental health and neurological disorders, medical conditions, medication, illicit drug use, or alcohol intake.

Overall, if the patient strictly adheres to their treatment plan, the prognosis is likely to be positive. Otherwise, the prognosis is poor, and relapse may occur. 

Patients with longstanding catatonia, or catatonia with schizophrenia, may be less likely to respond, and recovery may take longer or be harder to achieve. Therefore, early diagnosis and rapid initiation of treatment are vital.