How should catatonia be managed, including first‑line benzodiazepine therapy (lorazepam dosing), indications for electroconvulsive therapy, and supportive care?

Management of Catatonia

Lorazepam 1-2 mg IV or IM is the first-line treatment for catatonia, repeated every 1-2 hours as needed, with electroconvulsive therapy (ECT) reserved for benzodiazepine-refractory cases or immediately initiated in life-threatening presentations such as malignant catatonia, excited catatonia, or severe malnutrition from food refusal. 1

First-Line Treatment: Benzodiazepines

Lorazepam is the preferred benzodiazepine for immediate management of catatonia. 1

Dosing Protocol

• Initial dose: 1-2 mg IV or IM 1
• Repeat every 1-2 hours as needed until catatonic symptoms resolve 1
• Response typically occurs within 2 hours in 62% of patients, and within 24 hours in 86% of patients 2
• Complete resolution of catatonic symptoms occurs in approximately 32% of patients with lorazepam alone, while 69% show improvement 3

Monitoring Requirements

• Continuous monitoring of vital signs, oxygen saturation, airway patency, and level of consciousness is required during and after benzodiazepine administration 1
• Be prepared to provide respiratory support, as benzodiazepines increase the risk of apnea, particularly when combined with other sedative agents 4
• Monitor for paradoxical agitation, which may occur especially in younger patients 4

Duration of Trial

• An adequate benzodiazepine trial is typically 3-6 days at therapeutic doses (3-6 mg/day) before considering the patient benzodiazepine-refractory 3, 2
• If no response within one week, proceed to ECT 2

Second-Line Treatment: Electroconvulsive Therapy (ECT)

ECT should be initiated when benzodiazepines fail after an adequate trial OR immediately in life-threatening situations. 1, 5

Immediate ECT Indications (Do Not Wait for Benzodiazepine Trial)

• Malignant catatonia with autonomic instability (temperature dysregulation, blood pressure instability, tachycardia, tachypnea) 1, 6, 7
• Excited catatonia (medical emergency requiring immediate bilateral ECT) 1
• Severe malnutrition from food refusal 1, 5
• Extreme suicidality 1, 5
• Florid psychosis with catatonia 4, 1
• Uncontrollable mania 1, 5

ECT Protocol for Catatonia

• Bilateral electrode placement is preferred from the outset for catatonia, rather than unilateral placement 4, 1, 5
• Treatment frequency: 2-3 times weekly 1, 5
• Most courses consist of 10-12 total treatments 1
• Response rates to ECT are 80-100% in catatonia 7

Anesthesia Protocol

• Methohexital is the preferred anesthetic agent 5
• Succinylcholine for muscle relaxation 5
• Consider atropine or glycopyrrolate to prevent vagally induced bradycardia 5

Monitoring During and After ECT

• During treatment: monitor seizure duration, airway patency, vital signs, and adverse effects 4, 5
• Post-treatment: observe in designated recovery area for at least 24 hours to monitor for tardive seizures (late seizures occurring after the ECT session) 4, 5
• Obtain neurology consultation if recurrent prolonged seizures or tardive seizures occur 4, 5

Managing Prolonged Seizures

• Seizures lasting longer than 180 seconds are considered prolonged 4
• Terminate with additional methohexital, diazepam, or lorazepam 4, 8
• Prolonged seizures are associated with greater postictal confusion, amnesia, and hypoxia-related risks 4

Supportive Care

Critical Monitoring Parameters

• Assess for and treat underlying reversible causes: metabolic derangements, hypoxia, infection, CNS events, medication effects or withdrawal (particularly benzodiazepines, opioids, anticholinergics) 4
• Monitor for autonomic instability in malignant catatonia: temperature, blood pressure, heart rate, respiratory rate 6, 7
• Maintain hydration and nutrition: consider IV or subcutaneous fluids if evidence of dehydration 4

Medications to Avoid

• Never use typical antipsychotics in acute catatonia, as they can worsen the syndrome and precipitate neuroleptic malignant syndrome 1
• Avoid antiemetics that increase gastrointestinal motility (such as metoclopramide) if bowel obstruction is present 4

Adjunctive Pharmacologic Management for Agitation

If severe agitation occurs despite benzodiazepines:

• Haloperidol 0.5-2 mg every 1 hour as needed until episode is controlled 4
• Alternative agents: risperidone 0.5-1 mg twice daily, olanzapine 2.5-15 mg daily, or quetiapine 50-100 mg twice daily 4
• For refractory agitation despite high-dose neuroleptics, consider adding lorazepam 0.5-2 mg every 4-6 hours 4

Post-Treatment Management

• Initiate maintenance pharmacotherapy after ECT course to prevent relapse, tailored to the underlying psychiatric condition 4, 5
• Perform follow-up memory assessment at treatment termination and 3-6 months post-treatment 5
• Common side effects of ECT include headache, nausea, vomiting, muscle aches, confusion, and agitation, which typically resolve within the day of treatment 4, 5
• Memory impairment may persist for approximately 2 months post-treatment but is reversible 8, 5

Critical Pitfalls to Avoid

• Never delay ECT while attempting prolonged benzodiazepine trials in malignant catatonia or excited catatonia, as these conditions demand immediate definitive treatment with mortality rates approaching 50% if untreated 1, 7
• Do not mistake agitation for pain, which may lead to inappropriate escalation of opioids that can exacerbate delirium and worsen catatonia 4
• Recognize that catatonia can co-occur with delirium or coma, making diagnosis more challenging 6
• Be aware that catatonia secondary to medical conditions or comorbid with delirium may be less responsive to traditional benzodiazepine treatment 6