Management of Drug-Induced Catatonia from Quetiapine
Immediate Action: Discontinue Quetiapine and Continue Lorazepam
Yes, continue lorazepam for drug-induced catatonia that responded well to initial treatment, but taper it gradually over 1-2 weeks rather than maintaining it indefinitely. 1
Treatment Algorithm
Acute Phase (First 48-72 hours)
- Immediately discontinue quetiapine as it is the precipitating agent 1
- Continue lorazepam 1-2 mg every 4-6 hours until catatonic symptoms fully resolve 2, 1
- Monitor for symptom resolution using clinical assessment of mutism, rigidity, negativism, and posturing 3
- Most drug-induced catatonia resolves within 24-48 hours after removing the offending agent and administering benzodiazepines 1
Transition Phase (Days 3-14)
- Begin gradual lorazepam taper once symptoms have completely resolved for 48 hours 1
- Reduce dose by 25% every 2-3 days to prevent withdrawal and rebound symptoms 2
- Total lorazepam duration should typically not exceed 2 weeks for drug-induced catatonia without underlying psychiatric illness 1
Key Distinction: Drug-Induced vs. Primary Catatonia
This case differs fundamentally from primary or recurrent catatonia:
- Drug-induced catatonia typically does not require long-term benzodiazepine maintenance once the offending agent is removed 1
- Patients with schizophrenia and recurrent catatonia may require long-term treatment with clozapine or quetiapine, but this patient has no psychiatric history 4, 5
- Long-term benzodiazepine use (beyond 2-4 weeks) is reserved for periodic catatonia or catatonia associated with underlying psychiatric disorders 1, 4
Critical Monitoring During Taper
- Watch for re-emergence of catatonic symptoms (mutism, rigidity, posturing) during taper 1
- Monitor for benzodiazepine withdrawal (anxiety, tremor, insomnia) which can be confused with catatonia recurrence 2
- If symptoms recur during taper, hold at current dose for 3-5 days before attempting further reduction 1
Common Pitfall to Avoid
Do not continue lorazepam indefinitely "just in case" - this patient has no history of catatonia and the syndrome was clearly drug-induced. Prolonged benzodiazepine use in elderly patients increases fall risk, cognitive impairment, and paradoxical agitation risk (10% of elderly patients) 2. The appropriate approach is time-limited treatment with gradual discontinuation once the precipitant is removed and symptoms resolve 1.
If Catatonia Recurs After Lorazepam Discontinuation
- Re-evaluate for other organic causes (infection, metabolic derangement, CNS pathology) 1
- Consider that this may represent underlying periodic catatonia rather than purely drug-induced, requiring psychiatric consultation 4
- Restart lorazepam and consider longer-term management strategies only if recurrence occurs without re-exposure to quetiapine 1, 4