Pharmacological management

Lorazepam is the first line choice. In general, catatonia responds more reliably to short-acting benzodiazepines or Z-drugs, but some patients will also respond to longer-acting. Some centres have developed treatment plans using diazepam to allow for less frequent dosing.

Where patients have been treated with Lorazepam, and catatonia resolves, there needs to be patient-tailored consideration around how soon and at what pace to reduce Lorazepam. The treating team should be satisfied that any underlying cause for the catatonia has been appropriately addressed. The rate of reduction is likely to mirror, to some degree, the duration of time they have been on Lorazepam. Reductions should be gradual, with monitoring for recurrence of catatonic symptoms. Prescribers should be mindful of the non-linear change in receptor occupancy with benzodiazepine dose changes, with increasingly small dose reductions being advised to avoid withdrawal or rebound phenomena. On reaching the lowest doses of Lorazepam, conversion may be made to diazepam to facilitate gradual and small reductions. Consideration may be given to the withdrawal schedules at the website benzo.org.uk .

Another reference text may be the 2024 Maudsley Deprescribing Guidelines. In difficult cases, it may be that discussion with addictions psychiatry may be beneficial.

Other drugs with plausible mechanisms have been tried in catatonia, such as dopamine agonists (e.g. Bromocriptine) or those with other mechanisms (e.g. Memantine and Amantadine are NMDA receptor antagonists). None are as well established as Lorazepam and ECT, and some may exacerbate or cause psychosis.

Dopamine agonists have been reported in case studies to occasionally relieve catatonia which is resistant to benzodiazepines.