Parenteral lorazepam’s unavailability in Australia and the impact for catatonic patients

To the Editor

Catatonia is often under-recognized and undertreated in medicine. Delays in effective evidence-based treatment can lead to significant complications.

Mr X, a 65-year-old man with a mild intellectual disability and no past psychiatric history, presented with abrupt onset catatonic symptoms consisting of immobility, decreased responsiveness and negativistic phenomena. He was hospitalized and an organic etiology was strongly considered given a positive venereal disease research laboratory (VDRL) test, delaying the diagnosis of catatonia by 6 weeks. Following diagnosis of catatonia, 6 mg/day of oral lorazepam and 3 mg/day of subcutaneous clonazepam was trialed for 2 weeks with little beneficial effect. He was subsequently transferred to a tertiary hospital for electroconvulsive therapy (ECT). At presentation, his Bush-Francis Catatonia Rating Score was 21.

Mr X required a protracted course of ECT (19 bilateral) to achieve sustained response. Once treatment ended, he exhibited an elevated mood, confirming bipolar disorder as the etiology for his catatonia. He developed complications due to his prolonged immobility and posturing, including deep vein thrombosis and significant muscle contractures.

The delayed response to ECT is likely related to his prolonged catatonia presentation being initially misdiagnosed and inadequately treated prior to commencing ECT. Duration of catatonic symptoms is an indicator for ECT response (Narayanaswamy et al., 2012). The use of oral benzodiazepines and lack of availability of parenteral lorazepam possibly prolonged his episode of catatonia and contributed to the development of complications and delayed ECT response. Parenteral lorazepam is the recognized first-line treatment for catatonia with response rates between 67% and 79% (Sienaert et al., 2014), and occurring usually between 3 and 7 days (Tibrewal et al., 2010). Oral benzodiazepines including oral lorazepam have been less studied in the literature in catatonia compared to the parenteral formulation.

It is concerning that parenteral lorazepam is not readily available in Australia. Severe catatonia often results in patients unable to take oral medications, essentially leaving parenteral medication as the only available first-line intervention before proceeding to ECT. Currently, parenteral lorazepam is only available through a formal submission to the Special Access Scheme with local ethics approval required and a registry of prescribers listed with reports submitted annually. These significant barriers and lack of supply of parenteral lorazepam in Australia through pharmaceutical companies suggest catatonia might not be appropriately or adequately treated. It may also result in over-utilization of ECT. The authors would suggest that the Therapeutic Goods Administration be approached with modifications made to enable parenteral lorazepam to be readily available for clinicians to use in treating catatonia.