Question from a Member:
We have a [catatonic] patient on haloperidol 15 mg twice daily and not seen much improvement yet. Any data on which antipsychotics are preferred in terms of better efficacy for catatonic patients: second-generation antipsychotics or first-generation antipsychotics?
Very important! I want to emphasize strongly that the treatment of catatonia is primarily by benzodiazepines and electroconvulsive therapy (ECT) and NOT with antipsychotics.
The majority of patients with catatonia actually have a mood disorder rather than schizophrenia. But, in one study, about three-fourths of patients with catatonia later reported having had psychotic symptoms during the catatonia (Rasmussen et al., 2016). So, an antipsychotic may be needed if clear-cut and persistent psychosis is present in addition to the catatonia.
Special risks from antipsychotics in catatonia
High potency first-generation antipsychotics like haloperidol that have a high affinity for D2 receptors can (Pelzer et al., 2018; England et al., 2011):
– Worsen catatonia
– Increase confusion, agitation, and restlessness (England et al., 2011).
– Cause lethal catatonia/ neuroleptic malignant syndrome (NMS).
In one series of patients with neuroleptic malignant syndrome, all 17 patients with NMS had had catatonia (White and Robbins, 2000). In another case series, 3.5% of patients with catatonia treated with an antipsychotic developed NMS. Given the seriousness of NMS, that’s a scarily high number.
So, giving high dose haloperidol to a patient with catatonia, as was being done in our Member’s patient, is NOT a good idea!
1. Avoid antipsychotics in patients with catatonia, if possible, until the patient has improved
This is due to the increased risk of NMS in patients with catatonia. It has been suggested that we should wait until the patient has improved with lorazepam and/or ECT and is eating, drinking, and able to walk around (Rasmussen et al., 2018).
But, if an antipsychotic is needed in a patient with catatonia, which antipsychotics should be preferred? As of May 2020, there is no published clinical trial of any antipsychotic for the treatment of catatonia. So, the clinical recommendations below are based on published case series, clinical experience, and expert opinion.
2. Avoid high potency first-generation antipsychotics
Instead, second-generation antipsychotics should be preferred.
3. Clozapine may be a particularly good choice. Multiple authors have recommended clozapine for patients with catatonia. In one case series, while other second-generation antipsychotics were not consistently helpful, all seven patients with catatonia who were treated with clozapine benefited (England et al., 2011).
4. Consider lurasidone or cariprazine?
A large percentage of patients who present with catatonia actually have bipolar disorder and are in a state of severe, stuporous depression. So, if there is a past history of known or suspected bipolar disorder or a family history of bipolar disorder, ECT may be the best treatment. Though there is no published data to support this, among antipsychotics, lurasidone or cariprazine have the advantage of also having demonstrated efficacy in bipolar depression.
5. Consider aripiprazole, olanzapine, or quetiapine?
If clozapine is not an option or does not work, the other second-generation antipsychotics that may be considered are olanzapine, aripiprazole, or quetiapine (Beach et al., 2017; Yoshimura et al., 2013; Martényi et al., 2001).
But, I want to emphasize that it is not clear which second-generation antipsychotics other than clozapine should be preferred for the treatment of catatonia.
Simple and Practical Medical Education thanks Henry Nasrallah, MD (bio) for kindly reviewing this article (on May 12, 2020) and his helpful suggestions that improved it.
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Rasmussen SA, Mazurek MF, Rosebush PI. Catatonia: Our current understanding of its diagnosis, treatment and pathophysiology. World J Psychiatry. 2016 Dec 22;6(4):391-398. doi: 10.5498/wjp.v6.i4.391. eCollection 2016 Dec 22. Review. PubMed PMID: 28078203; PubMed Central PMCID: PMC5183991.
White DA, Robins AH. An analysis of 17 catatonic patients diagnosed with neuroleptic malignant syndrome. CNS Spectr. 2000 Jul;5(7):58-65. PubMed PMID: 18197157.
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Thank you! Great article.
Rajnish Mago, MD says
Thank you, Amethyst!