Can antipsychotics (Antipsychotic medications) exacerbate catatonia?

From the Guidelines

Yes, antipsychotics can worsen catatonia in some patients, particularly those with high-potency typical antipsychotics like haloperidol, fluphenazine, and trifluoperazine, which can exacerbate catatonic symptoms or even trigger catatonia in vulnerable individuals. The mechanism involves these medications' strong dopamine D2 receptor blockade, which can disrupt the balance of neurotransmitters that may already be dysregulated in catatonia 1. If a patient with catatonia requires antipsychotic treatment, lower-potency atypical antipsychotics such as quetiapine or olanzapine are generally safer options.

Some key points to consider when treating catatonia include:

• The preferred first-line treatments for catatonia typically include benzodiazepines (particularly lorazepam 1-2mg every 4-6 hours) and electroconvulsive therapy (ECT) rather than antipsychotics 1.
• When treating a patient with catatonia who has an underlying psychotic disorder, it's often recommended to first resolve the catatonic symptoms with benzodiazepines before cautiously introducing antipsychotics if needed.
• ECT may be considered for adolescents with severe, persistent major depression or mania with or without psychotic features, schizoaffective disorder, or, less often, schizophrenia, especially when affective symptoms are prominent or when catatonia is present 1.
• The use of antipsychotics in patients with catatonia should be approached with caution, and the benefits and risks of treatment should be carefully weighed, taking into account the potential for worsening catatonic symptoms 1.

From the Research

Catatonia and Antipsychotics

• Catatonia is a syndrome associated with several mental illness disorders and medical conditions, including schizophrenia, mania, depression, hyponatremia, cerebral venous sinus thrombosis, and liver transplantation 2.
• The use of antipsychotics in catatonia is a topic of interest, with evidence suggesting that classical antipsychotics may aggravate non-malignant and malignant catatonia (MC) 3.
• Atypical antipsychotics, on the other hand, may be useful in non-malignant catatonia, with case reports and retrospective studies showing a reduction in catatonic symptoms upon treatment with these medications 3.
• However, caution is advised when using atypical antipsychotics in catatonia, as cases of neuroleptic malignant syndrome (NMS) have been linked to treatment with these drugs 3, 4.

Risks and Benefits of Antipsychotics in Catatonia

• Antipsychotics should be used with caution in the presence of catatonic signs, as they can induce motor side effects such as akathisia, (tardive) dyskinesia, and dystonia 4.
• Dopamine-modulating second-generation antipsychotics, such as clozapine and aripiprazole, may be effective in some patient populations with catatonia 5.
• The treatment of catatonia often involves the use of benzodiazepines, such as lorazepam, which can be used in combination therapy with antipsychotics 2, 5.
• Electroconvulsive therapy (ECT) is also a definitive treatment for catatonia, particularly in cases where other treatments have failed 2, 5.

Case Reports and Studies

• A case report published in 2007 described the successful treatment of catatonia with olanzapine and amantadine in a 19-year-old woman who did not respond to lorazepam 6.
• Another study published in 2024 highlighted the importance of recognizing catatonia early and initiating appropriate treatment to achieve a favorable outcome, with benzodiazepines, ECT, and N-methyl-D-aspartate antagonists being the cornerstones of catatonia therapy 5.