Electroconvulsive therapy in catatonic patients: Effcacy and predictors of response Federica Luchini, Pierpaolo Medda, Michela Giorgi Mariani, Mauro Mauri, Cristina Toni, Giulio Perugi Federica Luchini, Pierpaolo Medda, Michela Giorgi Mariani, Mauro Mauri, Cristina Toni, Giulio Perugi, Department of Experimental and Clinic Medicine, Section of Psychiatry, University of Pisa, 56100 Pisa, Italy Cristina Toni, Giulio Perugi, Institute of Behavioural Science, G.De Lisio, 56100 Pisa, Italy Author contributions: All authors contributed to this manuscript. Confict-of-interest: All the authors report no confict of interest relevant to this work. Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/ licenses/by-nc/4.0/ Correspondence to: Giulio Perugi, MD, Department of Experimental and Clinic Medicine, Section of Psychiatry, University of Pisa, Via Roma 67, 56100 Pisa, Italy. giulio. perugi@med.unipi.it Telephone: +39-05-0992559 Fax: +39-05-02219787 Received: September 26, 2014 Peer-review started: September 28, 2014 First decision: November 19, 2014 Revised: February 12, 2015 Accepted: March 5, 2015 Article in press: March 9, 2015 Published online: June 22, 2015 Abstract Recent evidence favors the view of catatonia as an autonomous syndrome, frequently associated with mood disorders, but also observed in neurological, neurodevelop- mental, physical and toxic conditions. From our systematic literature review, electroconvulsive therapy (ECT) results effective in all forms of catatonia, even after pharmacotherapy with benzodiazepines has failed. Response rate ranges from 80% to 100% and results superior to those of any other therapy in psychiatry. ECT should be considered frst-line treatment in patients with malignant catatonia, neuroleptic malignant syndrome, delirious mania or severe catatonic excitement, and in general in all catatonic patients that are refractory or partially responsive to benzodiazepines. Early intervention with ECT is encouraged to avoid undue deterioration of the patient’s medical condition. Little is known about the long-term treatment outcomes following administration of ECT for catatonia. The presence of a concomitant chronic neurologic disease or extrapyramidal deficit seems to be related to ECT non-response. On the contrary, the presence of acute, severe and psychotic mood disorder is associated with good response. Severe psychotic features in responders may be related with a prominent GABAergic mediated deficit in orbitofrontal cortex, whereas non-responders may be characterized by a prevalent dopaminergic mediated extrapyramidal deficit. These observations are consistent with the hypothesis that ECT is more effective in “top-down” variant of catatonia, in which the psychomotor syndrome may be sustained by a dysregulation of the orbitofrontal cortex, than in “bottom-up” variant, in which an extrapyramidal dysregulation may be prevalent. Future research should focus on ECT response in different subtype of catatonia and on effcacy of maintenance ECT in long-term prevention of recurrent catatonia. Further research on mechanism of action of ECT in catatonia may also contribute to the development of other brain stimulation techniques. Key words: Electroconvulsive therapy; Catatonia; Mood disorders; Schizophrenia; Benzodiazepines; Antipsychotics © The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved. REVIEW Submit a Manuscript: http://www.wjgnet.com/esps/ Help Desk: http://www.wjgnet.com/esps/helpdesk.aspx DOI: 10.5498/wjp.v5.i2.182 World J Psychiatr 2015 June 22; 5(2): 182-192 ISSN 2220-3206 (online) © 2015 Baishideng Publishing Group Inc. All rights reserved. World Journal of Psychiatry WJP 182 June 22, 2015|Volume 5|Issue 2| WJP|www.wjgnet.com