Catatonia

Article information
Title: The Effect of Benzodiazepines on Catatonia: A Systematic Review and Meta-Analysis
PubMed ID: 42009596
First Author Last Name: Bot et al.

Abstract:
Introduction:
Catatonia is a complex psychomotor syndrome associated with various psychiatric and somatic underlying disorders. Current treatment protocols include benzodiazepines and electroconvulsive therapy (ECT). Despite their widespread use, systematic evidence regarding efficacy and optimal benzodiazepine dosage remains limited. This systematic review and meta-analysis aims to evaluate the effectiveness of benzodiazepines in treating catatonia.

Methods:
A comprehensive search of PubMed, Embase, APA PsychInfo, and Cochrane central identified studies reporting benzodiazepine treatment outcomes in catatonia. Screening and data extraction were done by two independent researchers. A targeted meta-analysis was performed on cases and studies that provided clear documentation of the Bush Francis Catatonia Rating Scale (BFCRS) scores before and after treatment, along with well-defined dosage regimens. Finally, the relationship between dosage and BFCRS improvement was explored.

Results:
Of 1336 screened articles, 53 met inclusion criteria. Most were case series using lorazepam (a benzodiazepine) to treat catatonia, with dosages ranging from 2 to 60 mg/day with a median dose of 8 mg/day. The overall remission rate was 55%; overall response was 77%. Treatment duration varied, but predominantly did not exceed 1 week. Our targeted analysis showed an overall effect of -11.88 points on the BFCRS when a benzodiazepine was used in the treatment of catatonia with a Cohen's d = -3.15. In a meta regression, no significant dose-response relationship was found.

Conclusion:
Benzodiazepines are highly effective for treating catatonia, but optimal dosing remains unclear. The absence of a clear dose-effect relationship highlights the need for individualized treatment strategies and well-designed controlled studies to establish stronger evidence-based treatment guidelines.

Annotation

The finding:
This is a systematic review and meta-analysis study aim to evaluate the effectiveness of benzodiazepines on catatonia with the goal of identifying dose and response relationship. The study included 53 articles were published between 1983 and 2023. 70% of these studies used lorazepam with median dose 8 mg/day. Majority of studies has duration up to 1 week with overall average response of 77% and remission of 53%. Most of the studies used benzodiazepines either in multiple or alternating routes (e.g. start with IV then switch to PO). The response and remission rates were 31.3% and 0%, 79% and 35.6%, 66.5% and 36.5 respectively for the studies used only intramuscular, intravenous, or oral administration. The study showed that the mean difference BFCRS scores before and after intervention was −11.50 points (95% CI: −14.11 to −8.89), when standardized with the average SD of 4.0, corresponded to a Cohen's d of approximately 3. Though the authors found a trending association between higher doses and higher effect, their finding was not statistically significant.

Strength and weaknesses:
This systematic review and meta-analysis is one of the first studies and possibly with highest level of evidence evaluated the effectiveness of benzodiazepines, particularly lorazepam, with the goal of identifying optimal dosage. The study successfully demonstrated that lorazepam is an effective treatment with a very large effect size (d = −3.15) for catatonia treatment. The study also showed that only parenteral and oral lorazepam treatment has relatively higher remission rates compared to only intramuscular lorazepam treatment. However, there is only one RCT of 53 included studies and only 20 of them used for the meta-analysis portion. It is also important to note that authors discussed high heterogeneity in sample sizes, treatment duration, dosage, route and outcome measures of included studies. In addition, even the median dosage is 8 mg/day in the study, the authors were not able to show significant association between dosage and effect size.

Relevance:
Catatonia is a severe syndrome which is experienced by approximately 10% of psychiatric patients and also many patients with non-psychiatric medical comorbidities. Benzodiazepines, especially lorazepam, are widely used for treatment of catatonia but there is no consensus on the efficacy or optimal dosage. Based on this study, clinicians may expect to initiate lorazepam as 2 mg and titrate lorazepam to a median total daily dose of 8 mg or higher, with possibly combining or alternating administration routes, to achieve more than 75% response rate and more than 50% remission rate in 1-week treatment period. This study results may provide further evidence-based guidance for psychiatrists and other clinicians to utilize lorazepam more often for catatonia treatment given the strong evidence and effect size.

Article information
Title: Catatonia treatments and risk of recurrence
PubMed ID: 41935752
First Author Last Name: Patarroyo

Abstract:

Background:
Catatonia is a recurrent neuropsychiatric syndrome affecting approximately 9% of psychiatric inpatients, yet the impact of acute treatment strategies on long-term recurrence risk remains poorly understood. This study examined how treatments administered during acute catatonic episodes influence recurrence risk.

Methods:
We conducted a retrospective cohort study of 205 adults hospitalized with catatonia at a tertiary care center between 2001 and 2021. Catatonia diagnoses were confirmed by chart review using Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria. The primary outcome was time to a new catatonic episode, with patients censored at last follow-up if no recurrence was observed. Treatment exposure was ascertained from the Latest Catatonia Episode (LaCE) for non-recurrent patients and from the Nearest Antecedent Catatonia Episode (NACE) for those with recurrence. Cox proportional hazards models estimated adjusted hazard ratios for benzodiazepines, antipsychotics, electroconvulsive therapy, and mood stabilizers, controlling for age and.

Results:
Overall, 31% of patients experienced recurrence over a median follow-up of 6.4 years. Benzodiazepines, used in 88% of patients, were consistently protective against recurrence (adjusted hazard ratio 0.50, 95% confidence interval 0.27-0.94, p = 0.03). Antipsychotics demonstrated a biphasic effect: lower hazard of recurrence within 60 days (adjusted hazard ratio 0.36, 95% confidence interval 0.13-1.00, p = 0.05) but associated with increased hazard thereafter (adjusted hazard ratio 2.14, 95% confidence interval 1.08-4.254, p = 0.08).

Conclusions:
Benzodiazepines use was associated with sustained protection against catatonia recurrence. The time-dependent antipsychotic effect warrants careful consideration in maintenance treatment planning. While our retrospective design limits causal inference, these findings emphasize the need for prospective studies to optimize maintenance strategies and prevent recurrence.

Keywords:
Antipsychotics; Benzodiazepines; Catatonia; ECT; Recurrence.

Annotation

The finding:
Among 205 hospitalized patients followed over a median of 6.4 years, roughly one-third experienced a recurrent catatonic episode. Those who received benzodiazepines during their acute presentation showed substantially lower odds of subsequent episodes (adjusted hazard ratio 0.50). Antipsychotic medications exhibited a complex temporal pattern: patients on these agents in the immediate post-episode window (first two months) had reduced recurrence likelihood (aHR 0.36), yet this protective effect reversed beyond that window, with later follow-up associated with doubled recurrence risk (aHR 2.14). Mood stabilizers and electroconvulsive therapy failed to demonstrate statistically significant protective or harmful associations.

Strength and weaknesses:
Notable advantages include the extended observation period, validated diagnostic confirmation procedures, and appropriate statistical handling of time-dependent treatment effects. Key limitations stem from chart-based data collection, which precludes drawing firm causal conclusions and introduces bias toward patients whose treatment decisions reflected clinician judgment about illness severity. Generalizability is also constrained by the single tertiary-care Midwestern setting and inpatient-only sampling, which skews toward more severe presentations. Additionally, data regarding medication persistence, dosing patterns, and real-world adherence in the outpatient setting are not captured, and unreported relapses occurring at outside hospitals could inflate the apparent protection of the observed treatments.

Relevance:
Catatonia recurrence is something C-L psychiatrists grapple with regularly, often without much evidence to guide longer-term decisions. What makes this study useful is how it captures a real clinical tension we face at the bedside as antipsychotics can be tempting when there's an active psychotic or affective process driving the catatonia, but here their benefit seems to fade and possibly reverse over time, likely through the same dopaminergic pathways that link catatonia, NMS, and antipsychotic-induced catatonia. Benzodiazepines, on the other hand, appear to hold up as a protective option well beyond the acute phase, though prospective data will be important before leaning on that too heavily. When we're thinking about relapse prevention, it really does come back to understanding what's driving each patient's catatonia, which is the kind of diagnostic clarification C-L teams are well positioned to provide.