Sublingual Zolpidem Spray for Refractory Catatonia: A Case Report

Catatonia is a neuropsychiatric syndrome characterised by motor, behavioural, and speech abnormalities. Although benzodiazepines and electroconvulsive therapy (ECT) are considered first-line treatments, a proportion of patients fail to show improvement. Emerging evidence suggests role for zolpidem in treatment-resistant catatonia cases. A 52-year-old woman presented with a 10-year history of decreased interaction, reduced speech, staring, posturing, immobility, and dependence for activities of daily living. She was diagnosed with catatonia and had a Bush-Francis Catatonia Rating Scale (BFCRS) score of 9. Treatment with lorazepam was initiated and gradually escalated to 12 mg/day over 2 weeks, resulting in only transient improvement. Subsequently, 5 sessions of ECT were given with no significant improvement. A 12-week trial of trifluperazine was also given which did not bring changes in symptom profile. Zolpidem sublingual spray was initiated at 5 mg/day and increased to 10 mg/day. Following dose optimisation, the patient demonstrated significant improvement with restoration of spontaneous speech, increased activity, and improved social interaction. Her BFCRS score decreased from 9 to 0 and the improvement was sustained for more than 2 months. Zolpidem, a selective GABA-A receptor α1 subunit agonist, may improve catatonic symptoms through modulation of dysfunctional motor circuits. The sublingual spray formulation offers rapid absorption and ease of administration. This case highlights the potential utility of zolpidem sublingual spray as an effective treatment option for refractory catatonia and highlights the need for further research to establish its efficacy and safety.