ECT. If high doses of benzodiazepines are not effective within 48 to 72 hours, ECT should be considered.1,7 ECT should be considered sooner for patients with life-threatening catatonia or those who present with excited features or malignant catatonia.1,2,7 In patients with catatonia, ECT response rates range from 80% to 100%.2,7 Unal et al7 reported a 100% response rate if ECT was used as the first-line treatment (n = 5), and a 92.9% (n = 39) response rate after adding ECT to lorazepam. Lorazepam may interfere with the seizure threshold, but if indicated, this medication can be continued.2 A minimum of 6 ECT treatments are suggested; however, as many as 20 treatments have been needed.1 Mr. W required a total of 18 ECT treatments. In some cases, maintenance ECT may be required.2
Antipsychotics. Discontinuation of antipsychotics is generally encouraged in patients presenting with catatonia.2,7,8 Antipsychotics carry a risk of potentially worsening catatonia, conversion to malignant catatonia, or precipitation of NMS; therefore, carefully weigh the risks vs benefits.1,2 If catatonia is secondary to psychosis, as in Mr. W’s case, antipsychotics may be considered once catatonia improves.2 If an antipsychotic is warranted, consider aripiprazole (because of its D2 partial agonist activity) or low-dose olanzapine.1,2 If catatonia is secondary to clozapine withdrawal, the initial therapy should be clozapine re-initiation.1 Although high-potency agents, such as haloperidol and risperidone, typically are not preferred, risperidone was restarted for Mr. W because of his history of response to and tolerability of this medication during a previous catatonic episode.
Other treatments. In a recent review, Beach et al1 described the use of additional agents, mostly in a small number of positive case reports, for managing catatonia. These included:
- zolpidem (zolpidem 10 mg as a challenge test, and doses of ≤40 mg/d)
- the N-methyl-D-aspartic acid antagonists amantadine (100 to 600 mg/d) or memantine (5 to 20 mg/d)
- carbidopa/levodopa
- methylphenidate
- antiepileptics (eg, carbamazepine, topiramate, and divalproex sodium)
- anticholinergics.1,2
Lithium has been used in attempts to prevent recurrent catatonia with limited success.2 There are also a few reports of using transcranial magnetic stimulation (TMS) to manage catatonia.1
Beach et al1 proposed a treatment algorithm in which IV lorazepam (Step 1) and ECT (Step 2) remain the preferred treatments. Next, for Step 3 consider a glutamate antagonist (amantadine or memantine), followed by an antiepileptic (Step 4), and lastly an atypical antipsychotic (aripiprazole, olanzapine, or clozapine) in combination with lorazepam (Step 5).
When indicated, don’t delay ECT
Initial management of catatonia is with a benzodiazepine challenge. Ultimately, the gold-standard treatment of catatonia that does not improve with benzodiazepines is ECT, and ECT should be implemented as soon as it is clear that pharmacotherapy is less than fully effective. Consider ECT initially in life-threatening cases and for patients with malignant catatonia. Although additional agents and TMS have been explored, these should be reserved for patients who fail to respond to, or who are not candidates for, benzodiazepines or ECT.
CASE CONTINUED
After 5 ECT treatments, Mr. W says a few words, but he communicates primarily with gestures (primarily waving people away). After 10 to 12 ECT treatments, Mr. W becomes more interactive and conversant, and his nutrition improves; however, he still exhibits symptoms of catatonia and is not at baseline. He undergoes a total of 18 ECT treatments. Antipsychotics were initially discontinued; however, given Mr. W’s improvement with ECT and the presence of auditory hallucinations, oral risperidone is restarted and titrated to 2 mg, 2 times a day, and he is transitioned back to paliperidone palmitate before he is discharged. Lorazepam is tapered and discontinued. Mr. W is discharged back to his nursing home and is interactive (laughing and joking with family) and attending to his activities of daily living. Unfortunately, Mr. W did not followup with the recommendation for maintenance ECT, and adherence to paliperidone palmitate injections is unknown. Mr. W presented to our facility again 6 months later with symptoms of catatonia and ultimately transferred to a state hospital.
Related Resources
- Fink M, Taylor MA. Catatonia: A clinician’s guide to diagnosis and treatment. New York, NY: Cambridge University Press; 2006. • Carroll BT, Spiegel DR. Catatonia on the consultation liaison service and other clinical settings. Hauppauge, NY: Nova Science Pub Inc.; 2016.
- Benarous X, Raffin M, Ferrafiat V, et al. Catatonia in children and adolescents: new perspectives. Schizophr Res. 2018;200:56-67.
- Malignant Hyperthermia Association of the United States. What is NMSIS? http://www.mhaus.org/nmsis/about-us/ what-is-nmsis/.
Drug Brand Names
Amantadine • Symmetrel
Aripiprazole • Abilify
Asenapine • Saphris
Carbamazepine • Carbatrol, Tegretol
Carbidopa/Levodopa • Sinemet
Citalopram • Celexa
Clozapine • Clozaril
Divalproex Sodium • Depakote
Enoxaparin • Lovenox
Fluoxetine • Prozac
Haloperidol • Haldol
Lithium • Eskalith, Lithobid
Lorazepam • Ativan
Lurasidone • Latuda
Memantine • Namenda
Methylphenidate • Concerta, Ritalin
Mirtazapine • Remeron
Olanzapine • Zyprexa
Paliperidone palmitate • Invega Sustenna
Quetiapine • Seroquel
Risperidone • Risperdal
Risperidone long-acting injection • Risperdal Consta
Topiramate • Topamax
Zolpidem • Ambien