Medical complications can be fatal
Treatment usually starts with lorazepam
Benzodiazepines are a first-line option for the management of catatonia.2,5 Controversy exists as to effectiveness of different routes of administration. Generally, IV lorazepam is preferred due to its ease of administration, fast onset, and longer duration of action.1 Some inpatient psychiatric units are unable to administer IV benzodiazepines; in these scenarios, IM administration is preferred to oral benzodiazepines.
The initial lorazepam challenge dose should be 2 mg. A positive response to the lorazepam challenge often confirms the catatonia diagnosis.2,7 This challenge should be followed by maintenance doses ranging from 6 to 8 mg/d in divided doses (3 or 4 times a day). Higher doses (up to 24 mg/d) are sometimes used.2,5,8 A recent case report described catatonia remission using lorazepam, 28 mg/d, after unsuccessful ECT.9 The lorazepam dose prior to ECT was 8 mg/d.9 Response is usually seen within 3 to 7 days of an adequate dose.2,8 Parenteral lorazepam typically is continued for several days before converting to oral lorazepam.1 Approximately 70% to 80% of patients with catatonia will show improvement in symptoms with lorazepam.2,7,8
The optimal duration of benzodiazepine treatment is unclear.2 In some cases, once remission of the underlying illness is achieved, benzodiazepines are discontinued.2 However, in other cases, symptoms of catatonia may emerge when lorazepam is tapered, therefore suggesting the need for a longer duration of treatment.2 Despite this high rate of improvement, many patients ultimately receive ECT due to unsustained response or to prevent future episodes of catatonia.
A recent review of 60 Turkish patients with catatonia found 91.7% (n = 55) received oral lorazepam (up to 15 mg/d) as the first-line therapy.7 Improvement was seen in 23.7% (n = 13) of patients treated with lorazepam, yet 70% (n = 42) showed either no response or partial response, and ultimately received ECT in combination with lorazepam.7 The lower improvement rate seen in this review may be secondary to the use of oral lorazepam instead of parenteral, or may highlight the frequency in which patients ultimately go on to receive ECT.
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