Refractory depression with catatonic features was remitted with administration of intravenous dopamine and consequent bupropion as maintenance treatment

To the Editor

The dopamine depletion hypothesis is linked to both depression and catatonia (Lane, 2015; Rajagopal, 2007). We report a case of refractory depression with catatonic features, complicated with bladder distension and subsequent urine retention related urosepsis. Intravenous dopamine given for septic shock successfully alleviated the symptoms of catatonic depression.

A 69-year-old woman with a 1-year history of depression consulted for sudden loss of taste (ageusia), followed by depression and anxiety, insomnia, appetite change and pessimistic thoughts. She did not respond to adequate dose and duration of sertraline, agomelatine, paroxetine and mirtazapine. Instead, symptoms progressed to intermittent immobility, mutism and acute urine retention due to catatonia-related bladder distension. She was hospitalized to an acute psychiatric ward (The Hamilton Depression Rating Scale [HAM-D]: 39; Bush-Francis Catatonia Rating Scale [BFCRS]: 25), receiving paroxetine (30 mg at bedtime), bethanechol (25 mg twice daily) and catheterization. On day 6 of hospitalization, urosepsis occurred, and her systolic blood pressure dropped to 70 mmHg. Dopamine (8.7 mcg/kg/min) vasopressor was given for 3 days and then gradually tapered within 4 days. Surprisingly, her immobility, mutism and depressed mood improved remarkably and she re-engaged in ordinary communication 6 days after the dopamine was initiated. Foley catheter was removed on day 21 with complete bladder emptying function. Antidepressant regimen was shifted to bupropion-slow release (SR) (150 mg twice daily), and she achieved remission by the fourth week of treatment (HAM-D: 21; BFCRS: 13). She was discharged from the hospital and continued on bupropion-(SR) as maintenance therapy until now.

Catatonia is typically associated with major depression, schizophrenia, bipolar disorder and other medical or surgical conditions. Its relationship to variable combination of gamma amino butyric acid (GABA)-A hypoactivity, dopamine (D₂) hypoactivity and glutamate N-methyl-d-aspartate (NMDA) hyperactivity in different brain circuits has been postulated (Rajagopal, 2007).

Since the permeability of the blood brain barrier is altered by pathologic states like sepsis, leakage of brain micro-vascular vessels facilitates the delivery of peripheral dopamine directly into the central nervous system (Ghosh et al., 2014). Therefore, we propose that catatonic depression is a status of predominant dopamine hypoactivity, which was quickly corrected by peripheral dopamine under systemic inflammation. The present case also demonstrates bupropion as maintenance therapy for catatonic depression.

To our knowledge, this is the first report showing the relationships between dopamine and catatonic depression with urosepsis. We propose dopamine as the first line agent for catatonic depression complicated with urosepsis and bupropion as a choice for catatonic depression.