It is well-known, I think, that benzodiazepines are the first-line treatment for acute catatonia. Among the benzodiazepines, lorazepam is the one used most often though several other benzodiazepines have also been used. Electroconvulsive therapy (ECT) is recommended when rapid response is essential or when benzodiazepines don’t work (Hasan et al., 2012).
But, the details of how to prescribe lorazepam for catatonia not well-known. Unfortunately, practice guidelines from major organizations note that benzodiazepines are recommended but don’t provide the details of how to use them to treat catatonia. So, on this page, I’ll provide practical details and recommendations about prescribing lorazepam for catatonia.
How much lorazepam per day?
The dose of lorazepam for catatonia varies from 2 to 16 (or even more!) mg per day (Pelzer et al., 2018; Sienaert et al., 2014).
Often, relatively low doses work really well (Rasmussen et al., 2018). But, some patients with catatonia don’t respond until higher doses of lorazepam are given (Rasmussen et al., 2018).
Please note the higher end of the dose range mentioned above. Clinicians sometimes conclude that lorazepam has not worked for the catatonia without going to higher doses.
Side effects? Sedation?
You may be wondering—“Won’t moderate or high doses of lorazepam cause excessive sedation, especially in a patient who is already lying still and not doing very little?”
Lorazepam treatment of catatonia is generally not associated with any significant side effects (Pelzer et al., 2018). Surprisingly, high doses of lorazepam are often tolerated by these patients without any sedation (Sienaert et al., 2014; England et al., 2011).
Of course, patients must still be carefully monitored due to the possibility of excessive sedation or even respiratory depression (Sienaert et al., 2014).
Route of administration
Initially, lorazepam is typically given by intramuscular, intravenous, or sublingual routes. There are several reasons why the oral route is not preferred:
1. Persons with catatonia often refuse oral medication and may spit it out.
2. By giving the lorazepam through a faster acting route, we can more easily see whether or not it has worked. If improvement occurs gradually, it is harder to know whether or not it was due to the lorazepam.
3. Using a faster acting route of administration makes it possible to give a second dose, if needed, only a few hours later.
Starting and titrating lorazepam
Typically, the first dose of lorazepam is 1 to 2 mg and many patients respond to the very first dose (Rasmussen et al., 2018). But here are some exceptions to this general point:
– An even lower starting dose should be used in patients who are elderly, have sleep apnea, have a high likelihood of having sleep apnea, or have other significant medical illness (Rasmussen et al., 2018).
– If the initial dose of lorazepam does not work, don’t assume that it won’t! The dose can be repeated three hours later and then, again, another three hours later (Rasmussen et al., 2018).
– If needed, the dose of lorazepam may be increased every one to three days.
For how long should lorazepam be tried before giving up on it?
Catatonia is usually a very serious condition and there is an urgency to get the patient better quickly. Thankfully, many patients respond to lorazepam after the first, or the first few, doses. Many others respond within a few days (Sienaert et al., 2014).
– But, we should know that, as in a case series from a leading medical center in the USA, the response to benzodiazepines may take days to weeks (England et al., 2011).
– How long it takes before lorazepam works seems to depend, in part, on how long the patient has had catatonia.
– A “lorazepam challenge test” is often used (Sienaert et al., 2014) and a quick and marked response to a benzodiazepine supports the diagnosis of catatonia. But, benzodiazepines do not work for every patient with catatonia. If the patient does not respond to a trial of lorazepam, we cannot conclude from this that the patient does not have catatonia!
If lorazepam works, for how long should it be continued?
Right off the bat, we should know that the duration for which lorazepam is used in patients with catatonia varies widely. But, here are some general points about the duration of treatment:
– Even in patients who do respond to lorazepam, the effect tends to wear off after three to five hours (Ungvari et al., 1994). So, repeated dosing is typically needed.
– Lorazepam may be needed for as long as the catatonic symptoms last (Pelzer et al.., 2018).
– In some patients, the catatonic symptoms return every time the benzodiazepine is reduced and long-term benzodiazepine treatment may be needed (Rasmussen et al., 2018; Grover and Aggarwal, 2011).
England ML, Ongür D, Konopaske GT, Karmacharya R. Catatonia in psychotic patients: clinical features and treatment response. J Neuropsychiatry Clin Neurosci. 2011 Spring;23(2):223-6. doi: 10.1176/jnp.23.2.jnp223. PMID: 21677256; PMCID: PMC3369314.
Grover S, Aggarwal M. Long-term maintenance lorazepam for catatonia: a case report. Gen Hosp Psychiatry. 2011 Jan-Feb;33(1):82.e1-3. doi: 10.1016/j.genhosppsych.2010.06.006. Epub 2010 Aug 10. PMID: 21353133.
Hasan A, Falkai P, Wobrock T, Lieberman J, Glenthoj B, Gattaz WF, Thibaut F, Möller HJ; World Federation of Societies of Biological Psychiatry (WFSBP) Task Force on Treatment Guidelines for Schizophrenia. World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Schizophrenia, part 1: update 2012 on the acute treatment of schizophrenia and the management of treatment resistance. World J Biol Psychiatry. 2012 Jul;13(5):318-78. doi: 10.3109/15622975.2012.696143. PMID: 22834451.
Pelzer AC, van der Heijden FM, den Boer E. Systematic review of catatonia treatment. Neuropsychiatr Dis Treat. 2018 Jan 17;14:317-326. doi: 10.2147/NDT.S147897. eCollection 2018. Review. PubMed PMID: 29398916; PubMed Central PMCID: PMC5775747.
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.
Ripley TL, Millson RC. Psychogenic catatonia treated with lorazepam. Am J Psychiatry. 1988 Jun;145(6):764-5. doi: 10.1176/ajp.145.6.764b. PMID: 3369569.
Sienaert P, Dhossche DM, Vancampfort D, De Hert M, Gazdag G. A clinical review of the treatment of catatonia. Front Psychiatry. 2014 Dec 9;5:181. doi: 10.3389/fpsyt.2014.00181. PMID: 25538636; PMCID: PMC4260674.
Ungvari GS, Leung CM, Wong MK, Lau J. Benzodiazepines in the treatment of catatonic syndrome. Acta Psychiatr Scand. 1994 Apr;89(4):285-8. doi: 10.1111/j.1600-0447.1994.tb01515.x. PMID: 8023696.
Weder ND, Muralee S, Penland H, Tampi RR. Catatonia: a review. Ann Clin Psychiatry. 2008 Apr-Jun;20(2):97-107. doi: 10.1080/10401230802017092. PMID: 18568581. This article is not available to me yet.
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