What is the recommended acute treatment for an adult presenting with acute catatonia?

Acute Treatment for Catatonia

Lorazepam is the first-line treatment for acute catatonia, administered at 1-2 mg intravenously or intramuscularly, with repeat dosing every 4-6 hours and rapid escalation to high doses (up to 8-24 mg/day) if initial response is inadequate. 1, 2

First-Line Pharmacological Treatment

Benzodiazepines—specifically lorazepam—demonstrate 70-79% complete response rates and should be initiated immediately upon diagnosis. 2

• Start with lorazepam 1-2 mg IV/IM as a test dose 1, 2
• If positive response occurs within 1-3 hours, continue scheduled dosing at 2 mg every 4-6 hours 1
• Rapidly escalate to high doses (8-24 mg/day) if symptoms persist, as very high doses are sometimes required and well-tolerated in catatonia 1
• The lorazepam-diazepam protocol has demonstrated 85.7% efficacy in rapidly relieving catatonia due to general medical conditions and substance-related causes 3

Alternative Benzodiazepine Approaches

• Diazepam can be used in combination with lorazepam as part of the lorazepam-diazepam protocol, particularly effective in medical and substance-induced catatonia 3
• When benzodiazepines fail or are not tolerated, zolpidem (a GABA-modulatory Z-drug) may provide rapid resolution, particularly in patients with post-traumatic stress disorder with secondary psychotic features 4

Second-Line Treatment: Electroconvulsive Therapy (ECT)

ECT demonstrates 85% efficacy and should be considered when benzodiazepines fail after 48-72 hours or when rapid resolution is medically necessary. 2

• ECT is more effective than benzodiazepines in malignant catatonia, where delayed treatment increases mortality risk 2
• In critically ill patients with catatonia (refusal to eat/drink, severe medical instability), bilateral electrode placement should be used initially 5
• Treatment frequency is typically 2-3 times weekly, with adjustments if significant confusion develops 5

Critical Treatment Algorithm

1. Immediate assessment (0-2 hours):

   • Administer lorazepam 1-2 mg IV/IM test dose 1, 2
   • Monitor for response within 1-3 hours 1
   • Simultaneously investigate underlying causes (autoimmune encephalitis, particularly NMDAR; thyroid disease; medication withdrawal; systemic lupus erythematosus) 1

2. If partial response (2-24 hours):

   • Escalate lorazepam to 2 mg every 4-6 hours 1
   • Continue rapid dose escalation up to 24 mg/day as tolerated 1

3. If no response after 48-72 hours:

   • Initiate ECT consultation immediately 2
   • Consider alternative GABA-modulators (zolpidem) in specific populations 4

4. If malignant catatonia features present:

   • Proceed directly to ECT without waiting for benzodiazepine trial failure 2
   • Malignant features include: autonomic instability, hyperthermia, rigidity, altered consciousness 6

Critical Investigations to Perform Concurrently

• Neuroimaging (MRI preferred) to exclude structural lesions 1
• EEG to assess for non-convulsive status epilepticus or encephalitis 1
• Neuronal autoantibodies in serum and CSF, particularly anti-NMDAR antibodies 1
• Thyroid function tests and electrolytes (especially sodium, as hyponatremia can induce catatonia) 6
• Medication review for recent benzodiazepine or clozapine withdrawal 6

Common Pitfalls to Avoid

• Do not use antipsychotics as first-line treatment—they demonstrate poor efficacy and may worsen catatonia or precipitate neuroleptic malignant syndrome 2
• Do not delay ECT in malignant catatonia—mortality increases significantly with treatment delays 2
• Do not underdose lorazepam—catatonia often requires doses far exceeding typical anxiolytic dosing (up to 24 mg/day) 1
• Do not attribute catatonia solely to psychiatric illness—multiple medical conditions (autoimmune encephalitis, cerebral venous sinus thrombosis, liver disease) can cause catatonia and require specific treatment 6, 1

Monitoring Requirements

• Continuous vital sign monitoring during acute treatment, particularly respiratory status when using high-dose benzodiazepines 1
• Serial catatonia rating scales (Bush-Francis Catatonia Rating Scale) to objectively track response 1
• Multidisciplinary collaboration between psychiatry and internal medicine/neurology is essential, as catatonia frequently has medical etiologies requiring concurrent treatment 1