Comprehensive Catatonia Guideline Released

While several catatonia guidelines predate this guideline, Oldham said that most of the guidelines focused on the occurrence of catatonia in specific patient populations, such as people with schizophrenia. “This is the first generic guideline that looks at catatonia across all possible etiologies,” he said.

Catatonia is associated with a host of psychiatric disorders, including mood disorders, autism spectrum disorder, and substance use disorders, Rogers said. Other illnesses may also increase the risk of catatonia, he added. “Data suggest that 20% of catatonia cases overall and 50% of those in an acute medical setting, like an ICU, involve no psychiatric comorbidity,” Rogers added. Catatonia has been linked with encephalitis, medication withdrawal, endocrine problems, and more.

In addition to describing the clinical features of catatonia, the guideline offers recommendations about how to narrow in on potential causes of catatonia, including when to seek guidance from other physicians, such as a neurologist.

Taking the time to uncover catatonia with a thorough assessment is satisfying, however, as catatonia can readily be treated, Rogers continued. Most patients will respond quickly to either benzodiazepines (preferably lorazepam) or electroconvulsive therapy, he noted. In cases of no or limited response to either of these, the NMDA-receptor medications amantadine and memantine are recommended.

The guideline emphasizes several groups of patients who might benefit from a more targeted treatment approach. For instance, if a patient has periodic catatonia (a rare type characterized by the rapid onset of motor disturbances that last a few weeks and then disappear for weeks, months, or even years), he or she might be most responsive to treatment with lithium.

“Another circumstance is catatonia due to clozapine withdrawal,” Oldham continued. “If that is suspected, then restart the patient on clozapine if there are no safety concerns.”

He noted that there is some debate over whether to administer antipsychotics in individuals with catatonia and schizophrenia (since these drugs can induce movement problems).

“A common refrain is that antipsychotics are an absolute no-no for catatonia, but these guidelines say judicious prescribing can be beneficial when catatonia is accompanied by psychosis,” he said. The guidelines recommend using second-generation antipsychotics and regular checking of a patient’s iron levels. (Low iron is a risk factor for neuroleptic malignant syndrome, a potentially life-threating disorder characterized by extreme muscle rigidity, elevated heart rate, and hyperthermia.) Co-administration of a benzodiazepine with the antipsychotic is also suggested.

Both Rogers and Oldham cautioned that while these guidelines offer many recommendations, the underlying clinical evidence is still sparse, and many knowledge gaps remain.

More education is needed about this serious syndrome to generate awareness about the disease, Oldham said, noting that he hopes the publication of the guideline helps. “People with catatonia are in a mental prison; they are often aware of their inability to speak or act in the way they should, and that causes tremendous anguish.” ■

“Evidence-Based Consensus Guidelines for the Management of Catatonia: Recommendations From the British Association for Psychopharmacology”