What is the first-line treatment for catatonia?

First-Line Treatment for Catatonia

Benzodiazepines, specifically lorazepam, are the first-line treatment for catatonia, with an initial dose of 1-2 mg IV or IM that can be repeated every 1-2 hours as needed. 1

Immediate Management Algorithm

Step 1: Assess Severity and Initiate Lorazepam

• Start lorazepam 1-2 mg IV or IM immediately upon diagnosis of catatonia 1
• Repeat dosing every 1-2 hours as needed based on clinical response 1
• Monitor vital signs, airway patency, and level of consciousness continuously during and after administration 1, 2
• Approximately 76% of patients will respond to lorazepam within days 3

Step 2: Identify Life-Threatening Presentations Requiring Immediate ECT

Skip benzodiazepine trials and proceed directly to bilateral ECT if any of the following are present:

• Excited catatonia (medical emergency requiring immediate definitive treatment) 1, 4
• Malignant catatonia with autonomic instability (fever, tachycardia, blood pressure changes) 1, 4
• Severe malnutrition from food refusal 1, 2
• Extreme suicidality 1, 4
• Florid psychosis with catatonia 1, 4
• Uncontrollable mania 1, 4

Critical pitfall: Never delay ECT while attempting prolonged benzodiazepine trials in excited or malignant catatonia—these conditions demand immediate bilateral ECT as speed of response is critical and benzodiazepines are typically inadequate 1, 4

Step 3: Assess Response to Lorazepam

• If symptoms resolve within 5-6 treatments: Continue lorazepam and transition to maintenance therapy 1
• If inadequate response after adequate trial (typically 5-6 treatments): Proceed to ECT 1, 2
• A positive response to initial parenteral lorazepam challenge predicts final lorazepam response 3

Second-Line Treatment: Electroconvulsive Therapy (ECT)

ECT Protocol for Benzodiazepine-Refractory Catatonia

• Use bilateral electrode placement from the outset in critically ill patients, as it is more effective than unilateral placement despite theoretical cognitive concerns that are reversible within months 1, 4
• For standard (non-critical) presentations, may begin with unilateral electrode placement to nondominant hemisphere, then switch to bilateral if inadequate response after 3-4 treatments 1
• Treatment frequency: 2-3 times weekly, with most courses consisting of 10-12 total treatments 1, 2
• Anesthesia with methohexital and muscle relaxation with succinylcholine 1, 2
• Monitor seizure duration, airway patency, vital signs, and adverse effects during treatment 1, 2
• Observe for at least 24 hours post-treatment for potential complications such as tardive seizures 1, 2

Alternative Benzodiazepine Options

When Lorazepam is Unavailable

• Midazolam may serve as an alternative or adjunctive therapy, with doses ranging from 4-32 mg IV daily or up to 48 mg oral daily 5
• Midazolam appeared at least partially effective as adjunctive therapy in 5 of 6 cases, though vast improvement typically required ECT 5
• Lorazepam-diazepam protocol has shown 85.7% effectiveness in rapidly relieving catatonia due to general medical conditions and substance-related causes 6

Critical Pitfalls to Avoid

• Never administer typical antipsychotics in acute catatonia—they can worsen the syndrome and precipitate neuroleptic malignant syndrome 1, 4
• Do not use unilateral electrode placement in excited catatonia where speed of response is critical 4
• Recognize that untreated catatonia can cause severe medical complications including rhabdomyolysis, renal failure, and death 4
• Be aware that sudden benzodiazepine discontinuation or non-adherence can lead to loss of response or need for higher doses 7

Maintenance Considerations

• Some patients may require indefinite benzodiazepine maintenance following failed tapering attempts 7
• Chronic tolerance requiring higher doses can develop, particularly in patients with prolonged catatonia 7
• Cross-taper from lorazepam to clonazepam is challenging and may result in relapse 7