Treatment

There are three aspects of treatment, all of which should be considered concurrently if possible:

1. Treat the underlying cause of the catatonia, whether organic or psychiatric
2. Treat the catatonia itself
3. Prevent and treat any complications arising from catatonia.

Treatment for catatonia

Benzodiazepines and electroconvulsive therapy (ECT) are both highly effective treatments for catatonia. Benzodiazepines are usually preferred as a first-line treatment, but ECT is sometimes given in life-threatening situations or where it is required to treat the underlying disorder as well.

The most commonly used benzodiazepine is lorazepam, which may be given orally, intramuscularly or intravenously. Very high doses are sometimes required. The optimal route depends on the circumstances: oral risks non-adherence; intramuscular entails painful injections, and intravenous requires a cannula, close monitoring and access to flumazenil.

1. Start treatment with lorazepam at 2mg twice daily oral/intramuscular/intravenous. (Lower doses may be required in certain at-risk groups, e.g. those with respiratory disease.)
2. If there is inadequate response after 24-48hr, increase the total daily dose by 2mg per day.
3. Keep increasing the dose, until either (a) the catatonia is effectively treated, (b) the patient is sedated or (c) a threshold of 24mg has been reached.
4. If lorazepam is effective, maintain the dose until treatment for any underlying disorder has been commenced. Then reduce the dose of lorazepam gradually. 

If lorazepam treatment is not successful, ECT is the next recommended step. Other medications with weak evidence supporting their use are amantadine, memantine, antipsychotics, carbamazepine, valproate and topiramate.

Prevention and treatment of complications

Even when compared to other patients with mental illnesses, patients with catatonia have a significantly increased mortality. Rates of certain medical complications are high, notably infections, rhabdomyolysis, pressure sores, dehydration, venous thromboembolism, cardiac arrhythmia, renal failure and neuroleptic malignant syndrome.