Can a patient with catatonia taking lorazepam (Ativan) 1 mg twice daily (BID) be tapered off the medication after 3 weeks?

Tapering Lorazepam After 3 Weeks in Catatonia

No, do not taper lorazepam after only 3 weeks in a patient with catatonia—this is far too early and carries substantial risk of catatonia relapse. The evidence consistently demonstrates that premature tapering or discontinuation of lorazepam in catatonia frequently triggers resurgence of catatonic symptoms, often within days of dose reduction.

Critical Evidence Against Early Tapering

The published literature on catatonia maintenance treatment reveals that many patients experience relapse when lorazepam is tapered prematurely:

• In a systematic review of 47 catatonia patients, relapse following lorazepam discontinuation was common enough to warrant indefinite maintenance treatment in many cases 1
• A case series found that 5 of 7 patients (71%) experienced catatonia resurgence within one week of lorazepam stoppage, with 3 requiring indefinite maintenance treatment 2
• Multiple case reports document that patients who initially responded to lorazepam required long-term maintenance, with relapses occurring during taper attempts 3, 4

Three weeks represents only the acute treatment phase—not the maintenance phase required before considering tapering.

Recommended Timeline and Approach

The appropriate timeline for considering a lorazepam taper in catatonia is measured in months, not weeks:

• Continue lorazepam at the effective dose (currently 1 mg BID = 2 mg/day) until both the catatonia AND the underlying psychiatric condition are fully treated and stabilized 1
• Establish a maintenance regimen for several months before attempting any taper 1
• When tapering is eventually attempted, follow benzodiazepine discontinuation guidelines: reduce by 10-25% of the current dose every 1-2 weeks, or slower (10% per month for long-term use) 5, 6

The FDA label for lorazepam explicitly states: "use a gradual taper to discontinue lorazepam or reduce the dosage" and "if a patient develops withdrawal reactions, consider pausing the taper or increasing the dosage to the previous tapered dosage level" 7.

Monitoring Requirements During Maintenance Phase

Before considering any taper, ensure the following:

• The catatonic symptoms have completely resolved and remained absent for an extended period (months, not weeks) 1
• The underlying psychiatric condition (if present) is fully treated and stable 1, 2
• The patient has demonstrated consistent adherence to the medication regimen 3
• Follow-up visits occur at least monthly to monitor for any subtle re-emergence of catatonic features 5

High-Risk Factors for Relapse

Certain patient characteristics increase the risk of catatonia relapse during tapering:

• Patients with schizophrenia or other psychotic spectrum disorders (the most common underlying condition in catatonia cases) 1, 2
• History of multiple catatonic episodes 2
• Previous relapse during a taper attempt 3, 2
• Non-adherence or sudden discontinuation history 3

For patients with these risk factors, indefinite maintenance treatment may be necessary rather than attempting discontinuation 3, 4.

Critical Safety Warnings

Abrupt discontinuation or premature tapering of benzodiazepines carries life-threatening risks:

• Benzodiazepine withdrawal can cause seizures and death—never stop suddenly 5, 7
• Withdrawal symptoms include anxiety, tremor, insomnia, sweating, tachycardia, confusion, and seizures 5
• In catatonia specifically, sudden lorazepam discontinuation can trigger rapid return of catatonic symptoms requiring higher doses or ECT 3, 2

Alternative Considerations

If there are concerns about continuing lorazepam at 1 mg BID:

• The current dose of 2 mg/day is within the FDA-approved range (1-10 mg/day) and is actually on the lower end for catatonia treatment 7
• Some catatonia patients require doses up to 18 mg/day for sustained response 3
• The lorazepam-diazepam protocol used in acute catatonia demonstrates that higher doses are often necessary and well-tolerated 8

If the concern is about long-term benzodiazepine use, recognize that catatonia represents a specific indication where the benefits of continued treatment clearly outweigh the risks of premature discontinuation 1, 4.

Practical Management Plan

For this patient at 3 weeks:

1. Continue lorazepam 1 mg BID without any dose reduction 1, 2
2. Ensure the underlying psychiatric condition is being adequately treated (antipsychotics, mood stabilizers, etc. as indicated) 1, 2
3. Monitor monthly for catatonic symptoms using a standardized scale (Bush-Francis Catatonia Rating Scale) 8
4. Reassess readiness for tapering after at least 3-6 months of complete symptom resolution 1
5. When tapering is eventually attempted, reduce by no more than 10% of the current dose per month 5, 6
6. If any catatonic symptoms re-emerge during taper, immediately return to the previous effective dose 7, 1

Some patients will require indefinite maintenance treatment—this is a legitimate outcome and should not be viewed as treatment failure 5, 3, 4.