Electroconvulsive Therapy Under Mechanical Ventilation for Catatonia-associated Respiratory Failure

Electroconvulsive therapy (ECT) is an effective, life-saving treatment for catatonia. However, comorbidities of catatonia, such as pneumonia or respiratory failure, can lead to difficulties in ECT. We report the case of a male patient in his 30s with schizophrenia who developed severe catatonia following discontinuation of clozapine. Furthermore, ineffective airway clearance subsequently led to the development of aspiration pneumonia and airway obstruction, which required mechanical ventilation on continuous sedation. During this time, the catatonia improved with high-dose lorazepam and midazolam; however, a spontaneous awakening trial (SAT) revealed that the catatonic symptoms had rapidly recurred following a reduction in the sedative dosage. Based on a discussion of these findings by a multidisciplinary team, ECT was begun while the patient was under mechanical ventilation. Two ECT sessions led to marked improvement in the catatonia, enabling a prolonged SAT to be performed. This confirmed the absence of catatonic symptoms, thereby permitting extubation. After the patient's respiratory status stabilized, 4 additional ECT sessions were administered. Finally, the patient was discharged without any recurrence of the catatonia or medical complications. This case demonstrates the importance of multidisciplinary collaboration in managing catatonia under complicated clinical conditions. Rather than delaying ECT because of its medical conditions, the treatments, including mechanical ventilation to protect the airway, should be carefully coordinated to enable the safe administration of ECT. Furthermore, SAT can serve as a valuable clinical tool for determining the appropriate timing and the need for ECT in catatonic patients under mechanical ventilation.