Catatonia is a severe neuropsychiatric syndrome that can leave patients trapped in states of profound motor immobility, mutism, or agitation. It’s a psychiatric emergency—yet far too often, patients with catatonia are caught in therapeutic limbo, receiving escalating doses of benzodiazepines while electroconvulsive therapy (ECT)—the most effective and often life-saving treatment—remains on hold.
Why the delay?
Despite clear evidence that ECT is highly effective for catatonia, especially when benzodiazepines fail, clinical inertia or institutional barriers often lead to prolonged treatment with high-dose lorazepam or diazepam. This can result in:
Research and clinical experience show that a significant proportion of patients with catatonia either partially respond to benzodiazepines or don’t respond at all. Increasing doses without reassessing the treatment trajectory may do more harm than good in these cases. ECT has a rapid and often dramatic impact when administered early, leading to complete remission in many cases.
Yet in practice, referrals for ECT are often made only after several days or weeks of unsuccessful pharmacologic trials, despite evidence-based guidelines recommending earlier consideration of ECT, particularly in life-threatening or malignant cases.
The reasons for delay are complex, including:
But time is brain and body.
For patients with catatonia, early recognition and a low threshold for ECT referral can be life-saving. It is not about replacing benzodiazepines; it’s about knowing when to move forward when first-line treatments fail.
As clinicians, we must recognize that in catatonia, waiting to “give the meds more time” can cost lives. Just as in stroke or myocardial infarction, the longer we delay the definitive treatment, the worse the outcome.
Let’s stop waiting. Let’s start treating.
Reference:
Sienaert, P., Dhossche, D. M., Vancampfort, D., De Hert, M., & Gazdag, G. (2014). A clinical review of the treatment of catatonia. Frontiers in Psychiatry, 5, 181. https://doi.org/10.3389/fpsyt.2014.00181
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