The patient, an 81-year-old woman with BD, presented with depressive catatonia associated with stupor, mutism, and extreme negativism.

Her family described a 3-month history of worsening mood, characterized by social withdrawal and anhedonia, spending most of her time in her room in bed. This occurred after the patientx decided to stop taking her medications. She reported difficulties falling asleep and early morning wakening, and would lie in bed worrying about how she would get through each day. This was associated with a decreased appetite resulting in a ten-kilogram weight loss. On admission, pressure areas were evident on her sacrum.

She had a long history of BD first diagnosed at age 24 characterized by multiple depressive and several manic episodes, with good inter-episodic functioning, and previous response to ECT when depressed. Her last episode had been 5 years prior. Psychiatric medications were Venlafaxine 150 mg mane, Mirtazapine 30 mg nocte, Sodium Valproate 500 mg nocte, 200 mg mane and Olanzapine 10 mg nocte.

Past medical history included diabetes mellitus type II, ischemic stroke, hyperlipidemia, and ischemic heart disease.

Prior to the current episode, she enjoyed neighborhood strolls with an aid, socializing with family, and playing bingo. She had no cognitive impairment and lived in residential aged care due to poor mobility.

Admission investigations were unremarkable [neuroimaging revealed an old posterior right Middle Cerebral Artery (MCA) territory infarct, blood investigations were normal including thyroid function tests]. An echo performed revealed severe Hypertrophic Obstructive Cardiomyopathy with a left ventricular outflow tract pressure gradient of 99 mmHg, deeming her medically high-risk for ECT.

The patient was admitted medically for rehydration and nasogastric (NG) feeding. Venlafaxine XR was increased up to 300 mg daily, Mirtazapine was increased to 60 mg via NG. An IV lorazepam challenge test, titrated up to 3 mg, was administered with no response. A cardiology review was conducted, and the patient was placed on a beta-adrenergic blocking agent. As an alternative treatment to ECT for her severe depression, trial of IV ketamine was commenced. Prior to commencement, Montgomery-Åsberg Depression Rating Scale (MADRS) was 50 and Bush Francis Catatonia Rating Scale (BFRS) was 18. Ketamine at a dose of 0.5 mg/kg (40 mg) administered IV over 40 min was delivered twice weekly.

Within 2 h of first treatment, the patient started communicating verbally, expressing an improvement in mood. She received a total of 11 treatments (see Figure 1) and once improvement plateaued (MADRS = 5), ketamine ceased, and she continued on oral antidepressants. Her appetite returned, she expressed improvement in her mood and increased enjoyment -enjoying watching sports on television. She started to engage in physical rehabilitation. She was followed-up in the community for 6 months and remained euthymic and was able to be referred back to her general practitioner (GP) for ongoing management.

The patient, a 76-year-old woman with BD, was admitted with catatonic depression, tachypnea, and low oxygen saturations (80–90% on room air).

The depressive episode commenced 6 weeks prior, triggered by a course of oral steroids following surgical removal of cataracts. The patient started to become more anxious and tearful, losing confidence in mobilizing independently and became withdrawn, remaining in bed. She was no longer enjoying reading or speaking with her friends, and had become mute. There was neurovegetative disturbance with loss of 8 kilograms. She displayed negativism when attempts were made to examine her.

The patient had a long history of BD, characterized by brief manic episodes and long depressive episodes with catatonia, which had responded to ECT previously. She was cognitively intact and her inter-episodic functioning was good. The patient’s psychiatric medications were nortriptyline 50 mg nocte, lithium 250 mg bd, and temazepam 10 mg nocte.

Past medical history included bronchiectasis, interstitial pulmonary fibrosis requiring a home oxygen concentrator, pulmonary embolus, hypertension, Gastroesophageal reflux disease, atrial fibrillation, and hyperlipidemia.

The patient was a retired librarian and remained cognitively intact. She was independent with activities of Daily Living (ADLs), enjoyed social outings, and had supportive children.

Admission investigations revealed a small pulmonary embolus. Despite optimizing her medical condition, she required ongoing supplemental oxygen and NG feeding.

Despite an IV lorazepam challenge, there was no improvement in the catatonic symptoms and ECT was commenced. At her first ECT treatment, she desaturated significantly, resulting in critical saturation levels and deeming her high risk for further anesthetics. Due to the patient’s pulmonary history and intermittent home oxygen saturation fluctuating around 90%, treatment of the PE was considered unlikely to provide an adequate or timely response in order to recommence her ECT. Treatment of her catatonic depressive symptoms was the priority so a trial of ketamine was commenced. Prior to treatment, her MADRS was 42 and BFCRS was 9. Ketamine at a dose of 0.5 mg/kg was administered IV over 40 min twice weekly.

There was a noticeable improvement following the first treatment, with a reduction in agitation, increased reactivity, and improvement in appetite (see Figure 1). Following her second treatment, the patient’s wry sense of humor returned, and she enjoyed spending time with her children and grandchildren. She described the treatments “surreal,” experiencing herself standing outside her body. Following her third treatment, she reported no further depressive symptoms, and requested to stop ketamine due to dissociative symptoms experienced during treatment. Her mood continued to improve over the next several days, with MADRS decreasing to 11. The patient was followed up in the community for over a year with no relapse of catatonic or depressive symptoms and was discharged from community psychiatric services.