Systematic review of catatonia treatment

Figures & data

Table 1 Characteristics of studies which investigated treatment of catatonia with benzodiazepines

Author	Country, period	Study type	na	Diagnosis of catatonia and measurement of treatment effect	Underlying diagnosis	Treatment	Treatment effect
Bush et al^Citation30	USA, not reported	Prospective cohort study	21	DSM-III-R, BFCRS	Affective d 54%, systemic disease 21%, psychotic d 11%, drug induced 11%	Lorazepam (PO, IM, IV), 4–8 mg/day during 5 days	Remission 76%
Dutt et al^Citation16	India, 2004–2008	Retrospective chart	51	BFCRS, ICD-10	Psychotic d 75%, affective d 14%, organic brain disease 8%	Lorazepam (PO, IM, IV), 4–12 mg/day during 3–4 days	Response 17.6%
England et al^Citation32	USA, 2004–2009	Retrospective chart	25	BFCRS, SCID	Psychotic d 52%, affective d 48%	Lorazepam up to 16 mg/day, co-medication not clear	Definitely beneficial response 28%, likely beneficial response 68%
Hatta et al^Citation25	Japan, 2003–2005	Prospective cohort	41	DSM-IV	Psychotic d 46%, affective d 34%, systemic disease 20%	Lorazepam (PO) 3 mg/day or diazepam (IV) up to 10 mg every 3–4 hours or flunitrazepam (IV) 0.02 mg/kg every 3–4 hours	Remission 2%
Huang et al^Citation20	Taiwan, 2002–2011	Retrospective chart	12	DSM-IV	Affective d	1) Lorazepam (IM) 2 mg, 2) repeat in case of little effect, 3) diazepam (IV) 10 mg every 8 hours	Remission 100%
Hung and Huang^Citation21	Taiwan, 2002–2005	Prospective cohort	7	DSM-IV	Major depressive d	1) Lorazepam (IM) 2 mg, 2) repeat in case of little effect 3) diazepam (IV) 10 mg every 8 hours	Remission 100%
Kritzinger and Jordaan^Citation23	South Africa, not reported	Open prospective	9	DSM-IV	Affective d 44%, psychotic d 33%, organic brain disease 33%	Lorazepam (IM) 2 mg once	Remission 66% within 2 hours, after 48 hours 0%
Lee et al^Citation26	Australia, 1996–1997	Prospective cohort	22	DSM-III-R, DSM-IV, ICD-10, BFCRS, MRS, PASS, SAS, Rosebush,b Lohr and Wisniewskic	Psychotic d 75%, affective d 17%, other 8%	Lorazepam (PO) or clonazepam (IV, IM), 4–8 mg/day during 3 days	Remission 73%, partial remission 27%
Lin et al^Citation22	Taiwan, 2002–2011	Prospective cohort	21	DSM-IV, BFCRS	Schizophrenia	1) Lorazepam (IM) 2 mg, 2) repeat in case of little effect 3) diazepam (IV) 1.25 mg/hour	Remission 100%
Narayanaswamy et al^Citation17	India, 2004–2005	Retrospective chart	99	DSM-IV, BFCRS	Psychotic d 49%, affective d 44%, unknown 7%	Lorazepam (IV) 2 mg every 6–8 hours during 3 days	Remission 32.3%
Northoff et al^Citation29	Germany, 1991–1994	Prospective cohort	18	DSM-III-R, Lohr and Wisniewski, Rosebush	Psychotic d 61%, affective d 28%, organic brain disease 11%	Lorazepam (PO or IV) 2–4 times a day 1–2.5 mg	Response 66%
Rosebush et al^Citation33	USA, not reported	Prospective open label	15	DSM-III-R	Affective d 47%, psychotic d 40%, other 13%	Lorazepam (PO or IV) 1–2 mg/day	Remission 80%, partial remission 6.6%
Seethalakshmi et al^Citation24	India, not reported	Prospective cohort	16	DSM-IV, BFCRS	Psychotic d 69%, affective d 6%, organic brain disease 6%, drug induced d 6%, other 12%	Lorazepam (IV) 1 mg every 10 minutes during 48 hours	Remission 75%, partial remission 18%
Tibrewal et al^Citation19	India, 2004–2005	Retrospective chart	99	DSM-IV, BFCRS	Psychotic d 49%, affective d 44%, unknown 7%	Lorazepam (IV) 1–2 mg every 6–8 hours during 3 days	Remission 32.3%, partial remission 68.7%
Ungvari et al^Citation27	China, 1992–1993	Prospective open label	18	DSM-III-R, Lohr and Wisniewski, Rosebush, McCall scaled	Psychotic d 56%, affective d 28%, other 16%	Lorazepam (PO) 2 mg or diazepam (IM) 10 mg during 48 hours	Improvement 89%
Ungvari et al^Citation14	China, not reported	Randomized controlled trial	20	DSM-IV, BFCRS	Schizophrenia	Lorazepam 2 mg 3 times a day over 6 weeks	Improvement 0%
Yassa et al^Citation28	Canada, not reported	Prospective open label	10	Not reported	Affective d 40%, psychotic d 40%, unknown 20%	Lorazepam (PO or IM), 2–3 mg/day, until remission	Remission 100%

Notes:

a Number of participants at final follow-up.

b Rosebush et al.³³

c Lohr and Wisniewski (1987).⁴⁹

d Modified McCall scale (1992).⁵⁰

Abbreviations: BFCRS, Bush–Francis Catatonia Rating Scale; d, disorder; DSM, Diagnostic and Statistical Manual of Mental Disorders; ICD, International Classification of Diseases; IM, intramuscular; IV, intravenous; MRS, Modified Rogers Scale; PASS, positive symptoms subscale; PO, per os, oral administration; SAS, Simpson–Angus Scale; SCID, structured clinical interview for DSM disorders.

Table 3 Characteristics of studies which investigated treatment of catatonia with antipsychotics

Author	Country, period	Study type	na	Diagnosis of catatonia and measurement of treatment effect	Underlying diagnosis	Treatment	Treatment effect
England et al^Citation32	USA, 2004–2009	Retrospective chart	7	BFCRS, SCID	Not specified (see Table 1)	Clozapine Olanzapine and quetiapine Risperidone and aripiprazole	Definitely beneficial response 85%, likely beneficial response 17% Varying results Negative effects
Hatta et al^Citation25	Japan, 2003–2005	Prospective cohort	28 19 19	DSM-IV	Not specified (see Table 1)	Chlorpromazine Risperidone Haloperidol	Remission 68% Remission 25% Remission 16%
Martenyi et al^Citation40	Austria, not reported	Open-label double-blind trials	35	DSM-IV, PANSS	Schizophrenia	Olanzapine	PANSS after 1 week (−13.1; p<0.001), after 6 weeks (−5.0; p<0.001)
Yoshimura et al^Citation41	Japan, 2008–2010	Retrospective chart	39	DSM-IV, BFCRS, CGI-I	Schizophrenia	Quetiapine	Used more in recovery and discharge compared to admission

Note:

a Number of participants at final follow-up.

Abbreviations: BFCRS, Bush–Francis Catatonia Rating Scale; CGI-I, Clinical Global Impression for improvement; DSM, Diagnostic and Statistical Manual of Mental Disorders; IV, intravenous; PANSS, Positive and Negative Syndrome Scale; SCID, structured clinical interview for DSM disorders.

Figure 1 Search and selection strategy. Flow diagram for included studies.

Table 2 Characteristics of studies which investigated treatment of catatonia with electroconvulsive therapy

Author	Country, period	Study type	na	Diagnosis of catatoniaand measurement of treatment effect	Underlying diagnosis	Treatment and co-medication	Treatment effect
Bush et al^Citation30	USA, not reported	Prospective cohort study	4	DSM-III-R, BFCRS	Affective d 75%, other 25%	ECT 3 times/week, bilaterally Medication: methohexital and succinylcholine. Neuroleptic drugs discontinued until the end of the treatment phase	Remission 100%
Cristancho et al^Citation34	USA, not reported	Case series	5	Not reported	Affective d 40%, psychotic d 40%, systemic disease (lupus) 20%	ECT unilaterally right, 8–12 sessions Medication: methohexital or etomidate added to succinylcholine	Remission 80%, partial response 20%
Dutt et al^Citation16	India, 2004–2008	Retrospective chart	42	BFCRS, ICD-10	Not specified (see Table 1)	ECT Medication: additionally most patients treated with antipsychotics. Some used antidepressants and mood stabilizers. Not clear if this was during ECT	Response 100%
England et al^Citation32	USA, 2004–2009	Retrospective chart	12	BFCRS, SCID	Not specified (see Table 1)	ECT Medication: majority required lorazepam through ECT course. Other co-medication not clear	Definitely beneficial response 83%, likely beneficial response 17%
Girish and Gill^Citation35	India, not reported	Double-blind, randomized controlled trial	14	BFCRS, ICD-10, Positive and Negative Syndrome Scale, Columbia side effect checklist, Simpson–Angus rating scale	Schizophrenia 64%, psychosis NOS 36%	ECT bilaterally 3 times/week plus placebo in ECT group. Sham ECT plus risperidone 4–6 mg/day in risperidone group Medication: lorazepam was stopped. ECT group: thiopentone, succinylcholine, atropine. Risperidone group: thiopentone	Catatonia scores reduced significantly in the ECT group. 50% continued to receive ECT beyond a 3-week period. ECT patients did not obtain total recoveryb
Hatta et al^Citation25	Japan, 2003–2005	Prospective cohort study	17	DSM-IV	Not specified (see Table 1)	ECT 3 times per week bilaterally Medication: atropine sulfate, thiopental and suxamethonium. Psychotropic medication discontinued during ECT	Remission 100%
Kugler et al^Citation38	USA, not specifically reported (last 3 years)	Retrospective chart Case series	13	DSM-5, CGI-I	Described per case (see Table 1)	ECT ultrabrief right unilateral, 3 times weekly. 3 cases switched to bilateral ECT 3 times weekly, 1 case started bilaterally Medication: methohexital and succinylcholine Other co-medication: described per case (see Table 1)	85% treatment responders; 76% complete remission, all treated with ultrabrief right unilateral ECT
Medda et al^Citation36	Italy, 2008–2014	Prospective, observational study	26	DSM-IV, BFCRS, CGI	Bipolar d	Bitemporal ECT 3 times weekly Medication: thiopental, rocuronium, sugammadex. Lorazepam was continued; last dose at least 12 hours prior to ECT. Other co-medication specified in Table 2	80.8% responders
Rohland et al^Citation39	USA, 1989–1992	Retrospective chart	28	DSM-III-R, Kahlbaum,^Citation1 Rosebushc	Affective d 61%, psychotic d 32%, organic brain disease 7%	ECT 3 times per week bilaterally Medication: methohexital, succinylcholine, glycopyrrolate, atropine (less frequent) and caffeine sodium benzoate	Remission 83.5%; primary symptoms 98%, secondary symptoms 74%
Raveendranathan et al^Citation18	India, 2007	Retrospective chart	63	ICD-10, BFCRS	Psychotic d 49%, affective d 41%, unknown 8%	ECT Medication: thiopentone and succinylcholine	Remission 88.89%, partial remission 11.11%
Van Waarde et al^Citation37	the Netherlands, 1991–2009	Retrospective chart	27	DSM-IV, CGI-I	Affective d 48%, psychotic d 44%, retardation/autism 8%	ECT Medication: 32% (9) had used antipsychotics just before ECT	Improvement 59%

Notes:

a Number of participants at final follow-up.

b ECT is superior over neuroleptics in catatonia.

c Rosebush et al.³³

Abbreviations: BFCRS, Bush–Francis Catatonia Rating Scale; CGI-I, Clinical Global Impression for improvement; d, disorder; DSM, Diagnostic and Statistical Manual of Mental Disorders; ECT, electroconvulsive therapy; ICD, International Classification of Diseases; IV, intravenous; SCID, structured clinical interview for DSM disorders.

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