Maintenance treatment of catatonia with benzodiazepines: A case series and literature review.

Objective: Benzodiazepines, particularly lorazepam, are good options for acute catatonia treatment. Published catatonia literature on benzodiazepine maintenance treatment and benzodiazepine tolerance is limited.

Methods: This is a chart review covering 30 years of clinical experience in the state of Kentucky, (United States of America), where there was no easy access to electroconvulsive therapy. Nine patients with prolonged catatonia requiring benzodiazepine maintenance treatment were selected for review.

Results: Three cases were switched from oral lorazepam to oral clonazepam, but relapses happened in 2 of them. Two patients lost their response to lorazepam and clonazepam. One with periodic catatonia needed ECT added to maintenance lorazepam. The other patient had 3 episodes of catatonia secondary to sudden clozapine withdrawal and required a restart of clozapine. Four patients were treated only with lorazepam. Two of them had relapses due to non-adherence or taper and needed indefinite lorazepam maintenance with no known relapses. One case initially responded to 1.5 mg/day of oral lorazepam but the dosage had to be increased to 18 mg/day to keep the response. Chronic tolerance requiring higher doses was present in 4 of the 9 patients and 2 of them were catatonic for many months.

Conclusions: Some patients may need to continue benzodiazepines indefinitely for maintenance treatment of catatonia following failed attempts at tapering. Sudden benzodiazepine discontinuation or non-adherence can lead to loss of benzodiazepine response or need for higher doses. A cross-taper from lorazepam to clonazepam can be accomplished, but is challenging and may result in relapse. (Neuropsychopharmacol Hung 2024; 26(4): 243-260)