Reviewing progress with treatment

For cases where catatonia is severe, response may be visible in terms of oral intake, and degree of time spent immobile or posturing. Beyond this, patients can be re-scored on the Bush Francis Catatonia Rating Scale to determine the degree of severity. It should be noted that distress and impaired quality of life are not directly assessed by such scoring, and MDT appraisal of such factors may also be material to progress.

With ECT, patients may show some response for a short period of time after receiving treatment, with this then waning. It may be found that this period of some improvement lengthens and increases in terms of degree of response. A lack of any response during ECT should prompt consideration of prescribing and ensuring any drivers/causes of catatonia are being addressed.

Consider involving other specialties early if the driver is not felt to be psychiatric, or it is challenging to ascertain if there is a driver. Neurology and neuropsychiatry may be able to advise on the likelihood of potential causes of catatonia (e.g. encephalitis), but also on some of the differentials of catatonia itself.

Confidence in the diagnosis of catatonia is important to allow prompt and assertive treatment, and to provide the best outcomes for patients. It is also important to convey diagnostic clarity to the wider MDT, especially to empower each member to provide effective care. It is important to avoid a situation where Lorazepam isn’t being given due to stupor being confused for sedation.

Most patients respond to Lorazepam, and even more to ECT, so should patients be refractory to both – it would be reasonable to discuss the case with colleagues/neuropsychiatry prior to progressing to rarer-used treatments such as NMDA receptor antagonists.