What is the management of catatonia?

From the Guidelines

Managing catatonia requires prompt recognition and treatment, typically starting with benzodiazepines as first-line therapy, and if ineffective, considering electroconvulsive therapy (ECT) as it has high efficacy rates of 80-100%. The treatment approach should prioritize the patient's safety and well-being, focusing on reducing morbidity, mortality, and improving quality of life. According to the practice parameter for the assessment and treatment of children and adolescents with bipolar disorder 1, ECT may be used if medications are not helpful or cannot be tolerated, especially in cases of catatonia.

Key Considerations

• Benzodiazepines, such as lorazepam, are the preferred initial treatment, starting at 1-2mg every 4-6 hours, which can be titrated up to 8-24mg daily if needed 1.
• Treatment should continue for several days to weeks, with improvement often seen within the first few days.
• If benzodiazepines are ineffective after an adequate trial (typically 3-5 days), ECT should be considered.
• Supportive care is essential, including hydration, nutrition, thromboprophylaxis for immobile patients, and monitoring for complications like pressure ulcers or aspiration.
• The underlying cause of catatonia should also be identified and treated, whether it's a psychiatric condition like schizophrenia or depression, or medical causes such as autoimmune encephalitis or metabolic disturbances.

ECT Considerations

• ECT is generally considered the treatment of choice for bipolar disorder in clinical situations such as pregnancy, catatonia, neuroleptic malignant syndrome, and any other medical condition in which more standard medication regimens are contraindicated 1.
• Potential side effects of ECT include short-term cognitive impairment, anxiety reactions, disinhibition, and altered seizure threshold.
• The clinician must balance the relative risks and benefits of ECT treatment against the morbidity of the disorder, the attitudes of the patient and family, and the availability of other treatment options 1.

Monitoring and Maintenance

• Regular reassessment using standardized rating scales like the Bush-Francis Catatonia Rating Scale can help monitor treatment response.
• Benzodiazepines can be gradually tapered once symptoms resolve, and maintenance treatment should focus on preventing relapse and managing underlying conditions.

From the Research

Management of Catatonia

• The use of lorazepam and electroconvulsive therapy (ECT) are effective treatments for catatonia, as shown in studies 2, 3, 4, 5.
• Lorazepam is a reasonable initial choice in the treatment of catatonia, with rapid consideration for ECT if there is no rapid response to lorazepam 2, 4.
• A modified treatment strategy using lorazepam and diazepam can rapidly relieve catatonic signs in patients with schizophrenia and mood disorders 3, 6.
• The response rate to lorazepam can be high, with studies showing response rates of 76% 4, 83.3% 6, and 85.7% 3.
• ECT can be effective in patients who do not respond to lorazepam, with studies showing that the combination of lorazepam and ECT can be superior to monotherapy 5.
• The Bush-Francis Catatonia Rating Scale can be used to monitor the response to treatment and has predictive value for treatment outcome 2, 4.

Treatment Strategies

• Lorazepam can be administered intramuscularly or orally, with a dose of 1-2 mg per injection 3, 6.
• Diazepam can be used if lorazepam is not effective, with a dose of 10 mg infused intravenously over 8 hours 3, 6.
• ECT can be used in combination with lorazepam, with the combination showing synergistic effects in some cases 5.
• The treatment strategy should be individualized based on the patient's response to treatment and medical comorbidities 2, 6.