Catatonia in general is a highly treatable illness.  The most important aspect to successful treatment is first recognizing the presence of a catatonic state.  A summary on recognition of catatonia is presented elsewhere on this website.

Evaluation

As noted, the use of a systematic catatonia rating system such as the Bush-Francis catatonia scale will greatly facilitate a diagnosis, and the scale can also be used to monitor the outcome of treatment.

And important part of the initial assessment of the case presenting with catatonia is whether autonomic abnormalities such as fever, sweating, and unstable vital signs are present. These are indicative of malignant catatonia or its drug-induced variant, neuroleptic malignant syndrome.  Patients having these severe forms of catatonia are likely to need treatment in specialized medical settings or intensive care units.  Their treatment may involve ECT more promptly than other cases.

There are no laboratory tests, X-rays, genetic, or brain imaging studies that can confirm or rule out a diagnosis of catatonia.  It remains a clinically defined and recognized syndrome. The diagnosis is based on recognizing signs and symptoms of catatonic, not any medical tests.  Some cases presenting with catatonia have been found to have antibodies to an NMDA receptors, and testing may be used in select patients.

Prognosis

In general the prognosis for a patient with catatonia is favorable. Even in the era before modern medical treatments, older scholars in Europe and the US noted a favorable prognosis, especially when catatonia was associated with depression or bipolar disorder.

Patients with a very chronic history of catatonia, or with chronic schizophrenia may show a less robust response to treatment. There are some case reports however those even chronic patients can respond to certain treatments.

A shorter duration of catatonic symptoms generally predicts a favorable response. In general the severity of catatonia does not predict response to treatment.  Even very severe cases are likely to respond.

Non-Specific Treatments

When catatonia is severe and persistent, the patient is at risk for medical complications. Such complications primarily arise from the patient being immobile and unable to have adequate nutrition. These include dehydration, nutritional compromise, and potential for blood clot formation. If treatment cannot be initiated promptly, measures should be taken to manage these potential complications in a medical setting.

Of course the best way to prevent such complications is by prompt recognition and treatment of the catatonic state.

Medications

Benzodiazepines are first-line treatments for catatonia. They have been in use for more than 25 years in catatonia, and familiarity with these generally safe agents is very common among psychiatrist and medical providers.

Given proper dosing which may require high range daily doses, a response rate of 60 to 80% can be expected.

It appears that lorazepam in particular is more effective than other medications of this class. It can be given by various routes such as intravenous, intramuscular, or by mouth.   Lorazepam can be given as a “diagnostic challenge” in which 1 to 2 mg is administered intravenously and a response should be seen within 15 to 30 minutes, occasionally sooner.  Such a positive response is a confirmation of the diagnosis.

The benzodiazepines are thought to work by action at GABA-A receptors in the brain.

Zolpidem is a related medication that also acts on GABA sites in the brain. It is a second-line medication and may have a more transitory positive effect compared to benzodiazepines. This medication is not available in an intravenous form but it can be given in an oral form and also used as a challenge test similar to lorazepam.

Various third and fourth line medications have been reported useful in case reports. These include amantadine and memantine, which are considered to work on NMDA and related systems in the brain.

ECT

ECT is recommended for severe and persistent catatonia where medications have failed. It is also recommended where a quick dramatic response is required such as cases of malignant catatonia where it can be life saving.

ECT will generally salvage a patient who is failed other treatments. It has been found in studies to be effective in this situation where medications such as lorazepam were ineffective or only produced a partial response.

In some cases ECT may be able to provide relief even when catatonia has been chronic for months or years.

The evidence for ECT suggests that bilateral ECT is more clearly effective than unilateral or other lesser forms of treatment such as TMS.

Catatonia in Children and Adolescents

Recent research has identified catatonia in children and adolescents, in particular those who have autism spectrum or other neurodevelopmental disorders.

It appears that these patients may also respond to lorazepam and in selected cases to ECT.