Should I continue Ativan (lorazepam) or taper it off upon discharge for a patient with a single episode of catatonia?

Should You Continue or Taper Lorazepam After a Single Episode of Catatonia?

For a single episode of catatonia lasting only one day in an inpatient setting, you should begin tapering lorazepam 2-3 days before discharge rather than continuing it long-term, as the risk of benzodiazepine dependence and withdrawal outweighs the benefit for such a brief, isolated episode. 1

Rationale for Tapering vs. Continuation

The decision to taper hinges on the duration and recurrence pattern of catatonia, not just its presence. A single one-day episode represents minimal exposure and does not establish the need for maintenance therapy that characterizes recurrent or prolonged catatonia.

Evidence Supporting Tapering for Single Episodes

• Start downward titration 2-3 days before discharge to establish the lowest effective maintenance dose and assess for withdrawal symptoms while still hospitalized 1
• The patient should be clinically stable for 24-48 hours before discharge with confirmed medication reconciliation 1
• Limit lorazepam to 1-2 weeks whenever possible to minimize tolerance, addiction, depression, and cognitive impairment 1

When Maintenance Treatment IS Indicated

The literature clearly distinguishes patients who need long-term lorazepam:

• Recurrent catatonia: Patients with multiple episodes (not your case) often require indefinite maintenance 2, 3, 4
• Prolonged catatonia: Episodes lasting weeks to months (not your case) may need extended treatment 3
• Failed taper attempts: Relapse during previous tapering attempts indicates need for maintenance 2, 4

Your patient has none of these risk factors with only a single one-day episode.

Specific Tapering Protocol

Pre-Discharge Tapering Schedule

Begin tapering 2-3 days before planned discharge 1:

1. Reduce by 25-50% every 1-2 days while monitoring for catatonic symptom re-emergence
2. Target the lowest effective dose or complete discontinuation if symptoms remain resolved
3. Maintain stable dose for 24 hours before discharge 1

Monitoring During Taper

Watch specifically for 5:

• Return of catatonic features (mutism, stupor, posturing, waxy flexibility)
• Benzodiazepine withdrawal symptoms (anxiety, tremor, insomnia, seizures)
• Changes in underlying psychiatric condition

Discharge Planning

• Arrange follow-up within 48 hours of discharge 1
• Provide clear written instructions about scheduled dosing (never PRN for catatonia maintenance) 1
• Document baseline catatonic symptoms before discharge to identify any recurrence 6

Critical Warnings About Continuation

The FDA explicitly warns that continued benzodiazepine use leads to clinically significant physical dependence 5:

• Abrupt discontinuation after continued use may precipitate life-threatening withdrawal reactions including seizures 5
• Protracted withdrawal syndrome can last weeks to more than 12 months 5
• Risk of abuse, misuse, and addiction increases with duration of use 5

Continuing lorazepam unnecessarily after a single brief episode creates iatrogenic dependence that will require eventual tapering anyway—but with greater difficulty and risk.

Common Pitfalls to Avoid

Pitfall #1: Continuing "Just to Be Safe"

This creates the very problem you're trying to prevent. The literature on catatonia relapse involves patients with recurrent or prolonged episodes 2, 3, 4, 7—not single brief episodes. Unnecessary continuation exposes your patient to dependence risk without evidence of benefit.

Pitfall #2: Abrupt Discontinuation

Never stop lorazepam abruptly, even after short-term use 5. The 2-3 day pre-discharge taper allows assessment for both catatonia recurrence and withdrawal symptoms while the patient is still hospitalized 1.

Pitfall #3: Discharge on PRN Dosing

Scheduled dosing is essential if any lorazepam is continued 1. PRN dosing is inappropriate for catatonia maintenance and increases risk of inadequate symptom control.

Pitfall #4: Inadequate Follow-Up

Schedule follow-up within 48 hours 1 to assess for:

• Late-emerging catatonic symptoms
• Benzodiazepine withdrawal (can occur days after discontinuation)
• Treatment of underlying condition causing the catatonic episode

Special Circumstances Requiring Reconsideration

Consider maintenance lorazepam only if:

• History of recurrent catatonia (multiple prior episodes) 2, 3, 4
• Previous relapse during lorazepam taper 2, 4
• Catatonia re-emerges during the pre-discharge taper 1
• Underlying condition known to cause recurrent catatonia (e.g., periodic catatonia, certain cases of schizophrenia) 3, 7, 8

In these cases, standard maintenance range is 2-3 mg/day divided into 2-3 doses with largest dose at bedtime 1.

Bottom Line Algorithm

For your patient with a single one-day episode:

1. Days -3 to -2 before discharge: Begin tapering lorazepam by 25-50% daily 1
2. Day -1 before discharge: Maintain stable reduced dose or discontinue if tolerated 1
3. Day of discharge: Patient should be on lowest effective dose or off lorazepam entirely 1
4. Post-discharge: Follow-up within 48 hours to assess for recurrence or withdrawal 1

This approach minimizes benzodiazepine exposure while maintaining safety through monitored tapering and close follow-up.