What is the optimal maintenance regimen for a patient with psychosis who responded to Ativan (lorazepam) but developed catatonia after Seroquel (quetiapine) reintroduction and Ativan titration?

Optimal Management for Recurrent Catatonia After Quetiapine Reintroduction

Discontinue quetiapine immediately and maintain the patient on lorazepam monotherapy without attempting to reintroduce antipsychotics until catatonia has been fully resolved for an extended period. 1, 2

Immediate Management

• Stop quetiapine completely as it is clearly precipitating recurrent catatonia in this patient 3, 4
• Restore lorazepam to the effective dose (the 2 mg BID that initially worked) rather than continuing titration downward 1, 2
• The patient demonstrated clear benzodiazepine responsiveness initially, which is the hallmark of treatable catatonia 5

Maintenance Strategy

Continue lorazepam at the therapeutic dose (2 mg BID or higher as needed) for prolonged maintenance rather than attempting rapid taper. 1, 2

• Research demonstrates that resurgence of catatonia occurs in the majority of patients within one week of lorazepam stoppage or tapering 1
• Multiple studies show that maintenance lorazepam therapy is often necessary to prevent recurrent episodes, with some patients requiring long-term treatment 1, 2
• In one case series, 66.7% of patients with recurrent catatonia required maintenance oral lorazepam at discharge to prevent further episodes 2

Critical Pitfall to Avoid

Do not attempt to reintroduce quetiapine or titrate down lorazepam prematurely. This patient has now demonstrated twice that quetiapine triggers catatonia, creating a dangerous pattern. 3, 4

• The temporal relationship is clear: catatonia emerged after quetiapine initiation, resolved with lorazepam, then recurred when quetiapine was restarted during lorazepam titration 1
• Gradual tapering of lorazepam does not reliably prevent catatonia recurrence in susceptible patients 1

Long-Term Antipsychotic Considerations

If antipsychotic treatment remains necessary for psychosis management after catatonia has been stable for an extended period:

• Consider clozapine as the preferred antipsychotic if future antipsychotic treatment is absolutely required 3, 2
• In patients with schizophrenia and recurrent catatonia, 63.2% were successfully maintained on clozapine without catatonia recurrence in one study 2
• Two case reports demonstrate that patients with recurrent catatonia under multiple antipsychotics achieved 2-year remission with continuous clozapine therapy 3
• Clozapine should only be introduced after complete catatonic remission and while maintaining therapeutic lorazepam doses 3, 2

Maintenance Lorazepam Dosing

Maintain lorazepam at 2 mg BID or increase as clinically indicated based on catatonia symptoms. 1, 2, 5

• Effective doses in recurrent catatonia range from 2 to 60 mg daily depending on severity 5
• For acute management of recurrent episodes, the lorazepam-diazepam protocol showed 79.4% full response rate in 68 episodes 2
• Monitor for tolerance, as some patients require escalating doses with repeated episodes 4

Alternative Considerations if Lorazepam Fails

If catatonia becomes refractory to lorazepam alone:

• Electroconvulsive therapy (ECT) is highly effective for lorazepam-resistant catatonia 4, 2
• Lamotrigine may have a role in preventing recurrent catatonia, with one case showing complete remission for 8 months when added to maintenance treatment 4
• Consider lamotrigine particularly if mood stabilization is needed or if there is suspected NMDA receptor involvement 4