What is the recommended treatment plan for a patient with a history of catatonia who is currently being treated with Ativan (lorazepam) 0.5mg twice a day, Namenda (memantine), and mirtazapine for sleep?

Treatment Plan for History of Catatonia on Current Medications

Continue lorazepam 0.5mg BID as maintenance therapy for catatonia history, as benzodiazepines remain the cornerstone of both acute and maintenance treatment, with some patients requiring indefinite continuation to prevent relapse. 1, 2

Current Medication Assessment

Lorazepam (Ativan) 0.5mg BID

• This dose is subtherapeutic for most catatonia cases - typical effective doses range from 2-6mg daily in divided doses, with some patients requiring up to 18mg daily for sustained response 3, 1
• The current 1mg total daily dose likely represents a maintenance regimen following successful acute treatment 1
• Do not discontinue or taper lorazepam - sudden discontinuation can trigger catatonia relapse and may result in loss of benzodiazepine responsiveness or require higher doses for future episodes 1
• Gradual taper should be used if discontinuation is attempted, but many patients need indefinite maintenance 3, 1

Memantine (Namenda)

• Memantine has documented efficacy as an adjunctive agent in catatonia treatment through NMDA glutamate antagonism 4, 5
• Particularly useful in patients with partial response to benzodiazepines or when electroconvulsive therapy is not accessible 4
• Continue current dose as adjunctive therapy 4, 5

Mirtazapine for Sleep

• Standard dosing is 15mg at bedtime, with increases up to 45mg daily if needed 6
• Dose changes should not occur more frequently than every 1-2 weeks 6
• If discontinuing, use gradual taper to avoid withdrawal reactions 6

Monitoring Recommendations

Watch for Catatonia Recurrence

• Monitor for early signs: staring, mutism, changes in muscle tone (waxy flexibility), posturing, movement pattern changes 7
• Any emergence of catatonic symptoms warrants immediate lorazepam dose increase - can escalate to 2-3mg given 2-3 times daily 3, 7

Benzodiazepine Tolerance Assessment

• Chronic tolerance requiring dose escalation occurs in approximately 44% of patients on long-term benzodiazepine maintenance (4 of 9 patients in one series) 1
• If catatonic symptoms re-emerge despite adherence, consider dose increase rather than switching agents 1
• Cross-taper to clonazepam is possible but challenging and carries relapse risk 1

Medication Adherence

• Non-adherence is a critical risk factor - 2 of 4 patients in one series relapsed due to non-adherence or attempted taper 1
• Emphasize the importance of consistent dosing without self-discontinuation 1

Common Pitfalls to Avoid

• Never abruptly discontinue lorazepam - this is the most common cause of catatonia relapse in maintained patients 1
• Do not assume the current low dose is inadequate - it may represent successful maintenance after higher acute dosing 1
• Avoid switching from lorazepam to other benzodiazepines unless absolutely necessary, as cross-taper carries relapse risk 1
• Do not add antipsychotics without careful consideration - high-potency agents like haloperidol can worsen catatonia through extrapyramidal effects 8

If Catatonia Recurs

1. Immediately increase lorazepam to 2mg three times daily (6mg total daily) 3
2. Continue memantine as adjunctive therapy 4
3. If inadequate response within 3-5 days, escalate lorazepam further (up to 10mg daily per FDA labeling) 3
4. Consider midazolam IV 4-32mg daily if oral lorazepam fails and ECT is not immediately available 7
5. Arrange electroconvulsive therapy consultation if benzodiazepine escalation proves insufficient 7, 1