Methylphenidate for Refractory Catatonia in a Patient With Schizophrenia When Electroconvulsive Therapy Was Unavailable: A Case Report

Background: Catatonia is a complex neuropsychiatric syndrome with motor, behavioral, and affective manifestations, including mutism, rigidity, and stereotypy. Benzodiazepines and electroconvulsive therapy (ECT) are standard treatments, but some patients have incomplete or inadequate responses, and access to ECT may be limited by medical, geographic, institutional, or logistical barriers. Occasional reports suggest that methylphenidate, a psychostimulant that enhances dopaminergic and noradrenergic signaling, may benefit catatonia refractory to conventional treatments. Case Presentation: A 68-year-old male with long-standing schizophrenia, managed with clozapine and ziprasidone, presented with catatonia characterized by rigid posturing, waxy flexibility, echolalia, and stereotypy. A trial of lorazepam resulted in oversedation without significant improvement; Bush-Francis Catatonia Rating Scale (BFCRS) score was calculated to be 14. Memantine, an NMDA receptor antagonist used off-label for catatonia, improved alertness but not core catatonic features. Because ECT was not feasible after the patient was not medically cleared at the available outpatient facility, methylphenidate (5 mg twice daily) was trialed, leading to notable improvement within days. The BFCRS decreased to 2, and residual symptoms resolved. Auditory hallucinations emerged transiently during recovery and subsided without intervention. Discussion: This case extends prior case reports of stimulant treatment for catatonia by describing an older adult with chronic schizophrenia who improved after low-dose methylphenidate when lorazepam was limited by oversedation and ECT was not feasible. The temporal sequence suggests methylphenidate was the more proximate contributor to recovery, although an additive effect with ongoing memantine cannot be excluded. The brief emergence of auditory hallucinations occurred during recovery and resolved despite continued methylphenidate, so it was not clearly attributable to stimulant-induced psychosis. Methylphenidate may warrant further investigation as a practical option when standard treatments are ineffective or unavailable. Conclusion: Methylphenidate may be a viable adjunctive treatment for catatonia that does not adequately respond to benzodiazepines, particularly when ECT is unavailable or impractical. Its rapid onset and widespread availability make it a potentially useful option, although controlled studies are needed to establish efficacy, optimal dosing, safety, and mechanism.