What is the treatment algorithm for catatonia?

Treatment Algorithm for Catatonia

First-Line Treatment: Benzodiazepines

Lorazepam is the first-line immediate treatment for catatonia, administered at 1-2 mg IV or IM, repeated every 1-2 hours as needed, with continuous monitoring of vital signs, airway patency, and level of consciousness. 1, 2

• Benzodiazepines, specifically lorazepam, are recommended by the American College of Physicians as the initial treatment for most catatonia presentations 1
• An adequate trial of benzodiazepines typically consists of 5-6 treatments before determining treatment failure 1
• Most patients with catatonia respond rapidly to low-dose benzodiazepines 3
• Diazepam is an alternative benzodiazepine option if lorazepam is unavailable 4

Critical Exception: Life-Threatening Presentations

Do not attempt benzodiazepine trials in excited catatonia, malignant catatonia with autonomic instability, or severe malnutrition from food refusal—these require immediate bilateral ECT. 1, 5

Second-Line Treatment: Electroconvulsive Therapy (ECT)

ECT should be initiated when benzodiazepines fail after 5-6 treatments or immediately in life-threatening situations. 1, 2

Indications for Immediate ECT (bypassing benzodiazepines):

• Excited catatonia with psychomotor agitation 1, 5
• Malignant catatonia with autonomic instability (fever, tachycardia, blood pressure changes) 5
• Severe malnutrition from food refusal 1, 2
• Extreme suicidality 1, 5
• Uncontrollable mania with catatonia 1, 5
• Florid psychosis with catatonia 1, 5

ECT Protocol:

Bilateral electrode placement should be used 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, 2

• For standard (non-emergent) catatonia presentations, treatment may begin with unilateral electrode placement to the nondominant hemisphere, then switch to bilateral if response is inadequate after 3-4 treatments 1
• Treatment frequency: 2-3 times weekly 1, 2
• Most courses consist of 10-12 total treatments 1
• Anesthesia: methohexital as the anesthetic agent with succinylcholine for muscle relaxation 1, 2
• Monitor seizure duration, airway patency, vital signs, and adverse effects during treatment 1, 2
• Post-treatment observation for at least 24 hours for potential complications such as tardive seizures 1, 5

Third-Line Treatment: NMDA Antagonists

For catatonia refractory to both lorazepam and ECT, NMDA antagonists such as amantadine and memantine should be considered. 4, 6

• Evidence is mounting for the use of NMDA antagonists in lorazepam-refractory catatonia 6
• These agents are particularly relevant given the proposed role of glutamate signaling abnormalities in catatonia pathophysiology 3

Alternative Agents in Specific Populations

• Zolpidem (a GABA-modulatory Z drug) may be preferable to benzodiazepines in patients with post-traumatic stress disorder with secondary psychosis who develop catatonia 7
• Dopamine-modulating second-generation antipsychotics (clozapine, aripiprazole) are effective in some patient populations 4

Critical Pitfalls to Avoid

Never administer typical antipsychotics in acute catatonia, as they can worsen the syndrome and precipitate neuroleptic malignant syndrome. 1, 5

• Do not delay ECT while attempting prolonged benzodiazepine trials in excited or malignant catatonia—these conditions demand immediate definitive treatment 1, 5
• Do not use unilateral electrode placement in excited catatonia; bilateral placement is indicated when speed of response is critical 5
• Recognize that untreated catatonia can cause severe medical complications including rhabdomyolysis, renal failure, and death 5
• Be aware that patients with longstanding catatonia or a diagnosis of schizophrenia may be less likely to respond to benzodiazepines 3

Underlying Condition Management

The catatonic symptoms must be treated before any underlying conditions can be accurately diagnosed, but both the catatonia and the underlying illness must ultimately be addressed. 3, 6

• Catatonia occurs with psychiatric disorders (schizophrenia, mood disorders, schizoaffective disorder) and medical conditions (hyponatremia, cerebral venous sinus thrombosis, anti-NMDA receptor encephalitis, neuroleptic malignant syndrome) 8, 3
• Benzodiazepine or clozapine withdrawal can precipitate catatonia due to increased excitatory neurotransmission 8