Treatment

Acute catatonia has a higher response rate to benzodiazepines than chronic catatonia. The first line treatment is Lorazepam. If an as-required dose has previously been given without any observed benefit, then the regular dose should be started at a higher dose.

Dosing can start at 1mg four times daily, or 2mg twice daily. Given the expectation that oral intake and activity levels may be best ~30-60 minutes after administration, timings may be chosen with reference to mealtimes.

The dose should be increased at 2-to-3-day intervals if there is no initial response (and some regions suggest more rapid increases e.g. up by 2-4mg every 1-2 days). After 2mg four times daily is reached, doses can either be given more often than four times per day, or the individual doses can be increased above 2mg.

Some patients may be unable to take Lorazepam orally (either tablet or oral solution), which may be due to negativism, psychosis, agitation, poor swallow or declining oral intake. In this case administration can be via intramuscular or intravenous route. Hesitancy around escalation of doses risks patients missing out on potential treatment response, and worsening of their clinical condition.

Consultant oversight is particularly important when high doses of Lorazepam are required, to ensure safe prescribing and balancing of risks against benefits. Doses as high as 48mg per day have been recorded in rare cases, but the vast majority of patients respond well to much lower amounts. The most suitable care setting for care and treatment should be considered, according to each individual patient’s needs.

Often there is a high initial response rate, but this is not always maintained. Loss of initial improvement, requiring increased dose to achieve similar benefit, often heralds the need for ECT. For patients on high doses of Lorazepam, or where there are concerns over sedation, there should be consideration of the availability of Flumazenil.

The first line treatment in chronic catatonia is also Lorazepam. However, there is a lower response rate than in acute catatonia. There is some evidence that a low serum iron predicts a poorer response to benzodiazepines. As with acute catatonia, inadequate response is an indication for ECT. Clozapine may be beneficial where psychosis is present.

Manic delirium presents a distinct management challenge. The symptomatic treatment for delirium (antipsychotics) can worsen catatonia, while the delirium can prompt special caution in use of the first line treatment of catatonia (benzodiazapines) or discontinuation of these. Some symptoms overlap or may be mistaken for those of the other condition. Treatment of the associated or underlying condition(s) is critical, and meticulous serial assessment of features of each (and response of each to treatment) is key to successful management.

Dopamine antagonists can exacerbate catatonia or precipitate neuroleptic malignant syndrome. The latter is increasingly viewed as a form of malignant catatonia. If a patient on high doses of antipsychotic medication presents with catatonia, an attempt to reduce the dose in order to ascertain whether an improvement in catatonia results is recommended. If so, but antipsychotic treatment remains necessary, switching to a low potency (e.g. Quetiapine) or partial dopamine agonist (e.g. Aripiprazole) is preferable.
Consideration of the specific patient circumstances is essential, as uncontrolled psychosis may drive catatonic symptoms, and in which case, the antipsychotic dose may need to be increased, or changed to an alternative.

Malignant catatonia is characterised by the presence of autonomic disturbance and may be fatal. Immediate treatment is vital. If adequate control is not achieved with benzodiazepines in 48hours (less if deterioration in clinical state) then urgent ECT is indicated. Depending on the levels of physical instability, care in a medical HDU or ICU environment may be required.

Lower doses of Lorazepam may be used, but titration is according to clinical response, with dosing going up to as high as 24mg per day.

Identification and treatment of any driving/causative factors is key – whether this be physical health or psychiatric. Lorazepam is first-line, but lower doses may be required for response. A starting dose may be 1mg twice daily. Benzodiazepines are recognised as worsening cognition and falls risk in the elderly, but it is important not to avoid their use when indicated for catatonia. Under-treated catatonia also increases falls risk (especially in those who are more frail and sarcopenic), along with a number of other physical health consequences. Assertive and proactive management is encouraged in patients who have lower physiological reserve, especially where oral intake is reducing or biochemistry is becoming deranged.

Intellectual disability

Broadly the same doses of Lorazepam are used as in the general adult population, although it is prudent to begin with a lower dose (1mg twice daily) and titrate upwards according to response.

Autism

Patients with autism and/or intellectual disability can still have catatonia secondary to physical health issues, or a mental illness, and it is essential not to allow diagnostic overshadowing to lead to inappropriate under-investigation. However, catatonia may be present in autism without other diagnoses, often (but not always) in the context of psychosocial stressors.

There is huge variation in symptom expression between individuals, and contributing aetiologies. Consequently, holistic assessment is needed to reach a successful management plan. Key to this is the identification (when possible) and management of precipitating stressors.

In mild catatonia, psychology and formulation-driven interventions may be the sole treatment. A ‘Psycho-Ecological Approach’ (Shah, 2019) may be one such model. The core facets of this are:

1. Psychological and ecological assessment and formulation
2. Identifying individual stress, anxiety and non-coping
3. Increasing awareness and avoiding misdiagnosis
4. Psycho-education and training
5. Reviewing and withdrawing ‘culprit’ psychiatric medication
6. Early identification
7. Increasing structure, routine and consistency
8. Implementing immediately strategies of support
9. Activity and stimulation therapy
10. Reducing decision making
11. Management of specific problems
12. Psychological interventions and support for high functioning autistic individuals.

In more severe catatonia, or when psychological interventions alone have not been beneficial, pharmacological and neuro-modulatory treatments are considered in the same fashion as with the general population. Psychological work may be utilised in collaboration. There is some evidence that Lorazepam treatment may be less effective for catatonia than is typically seen in the general population.