Journal Article Annotations
2023, 2nd Quarter

Catatonia

Annotations by Samuel Kohrman, MD
July, 2023

Evidence-based consensus guidelines for the management of catatonia: Recommendations from the British Association for Psychopharmacology

PUBLICATION #1 — Catatonia

Evidence-based consensus guidelines for the management of catatonia: Recommendations from the British Association for Psychopharmacology

Jonathan P Rogers, Mark A Oldham, Gregory Fricchione, Georg Northoff, Jo Ellen Wilson, Stephan C Mann, Andrew Francis, Angelika Wieck, Lee Elizabeth Wachtel, Glyn Lewis, Sandeep Grover, Dusan Hirjak, Niraj Ahuja, Michael S Zandi, Allan H Young, Kevin Fone, Simon Andrews, David Kessler, Tabish Saifee, Siobhan Gee, David S Baldwin, Anthony S David

Abstract: J Psychopharmacol. 2023 Apr;37(4):327-369. doi: 10.1177/02698811231158232. Epub 2023 Apr 11.

The British Association for Psychopharmacology developed an evidence-based consensus guideline on the management of catatonia. A group of international experts from a wide range of disciplines was assembled. Evidence was gathered from existing systematic reviews and the primary literature. Recommendations were made on the basis of this evidence and were graded in terms of their strength. The guideline initially covers the diagnosis, aetiology, clinical features and descriptive epidemiology of catatonia. Clinical assessments, including history, physical examination and investigations are then considered. Treatment with benzodiazepines, electroconvulsive therapy and other pharmacological and neuromodulatory therapies is covered. Special regard is given to periodic catatonia, malignant catatonia, neuroleptic malignant syndrome and antipsychotic-induced catatonia. There is attention to the needs of particular groups, namely children and adolescents, older adults, women in the perinatal period, people with autism spectrum disorder and those with certain medical conditions. Clinical trials were uncommon, and the recommendations in this guideline are mainly informed by small observational studies, case series and case reports, which highlights the need for randomised controlled trials and prospective cohort studies in this area.

Annotation

The finding:
This evidence-based multi-specialist consensus guideline offers a number of recommendations with varying degrees of strength. The highest strength recommendations are as follows:

Definition of catatonia: Catatonia should be diagnosed based on the presence of three or more catatonic signs, as in DSM-5-TR or ICD-11.
Use of a challenge test: When a diagnosis of catatonia is uncertain, a diagnostic challenge using lorazepam should be considered. In suspected or confirmed cases of catatonia, a lorazepam challenge may be used to predict future response to benzodiazepines.
General approach to treating catatonia: Where benzodiazepines have not resulted in remission, electroconvulsive therapy should be used.
Recommendations for catatonia in kidney, liver and lung disease: In mild or moderate hepatic impairment, lorazepam dosing does not usually need to be altered, but caution should be exercised when considering lorazepam in severe hepatic impairment.

Strength and weaknesses: (A few sentences on strengths and weaknesses)
This review offers an expanded set of recommendations to patients both in the general hospital/medical catatonia setting and also to other clinical populations with catatonia. Evidence-based recommendations appear appropriately rigorous. Given the relative dearth of high-powered clinical trials, recommendations are informed by smaller observational studies, case series and reports. Medical conditions associated with catatonia listed are not comprehensive and were considered outside the scope of this guideline.

Relevance: (A few sentences on the relevance of the findings for C-L psychiatrists)
This useful, rigorous, tiered evidence-based guideline on the management of catatonia offers recommendations that are practical for a broad clinical scope of practice. This work can be used in combination with more focused guidelines by ACLP, EAPM, and APM for patients with catatonia and medical illness and in the general hospital setting. Given the complex and ever-evolving understanding of pathogenesis and treatment of catatonia, these guidelines offer guidance to accompany (without substituting) clinical judgement.