Abstract
To the Editor,
Catatonia is a neuropsychiatric disorder involving motor and autonomic systems. 1 It is seen in 7% to 15% of acute psychiatric inpatients and needs prompt attention irrespective of its cause, whether functional or organic. 2 Lorazepam and electroconvulsive therapy (ECT) are preferred modalities of treatment.3,4 In the literature, lorazepam is preferred over other benzodiazepines, without much explanation. Here we present a case who responded to a single dose of clonazepam, which has forced us to think beyond the traditional approach. The informed consent has been taken from the patient to report the case report.
Case Report
A 21-year-old male, educated up to bachelor’s degree, previously diagnosed with schizoaffective disorder, was presented to psychiatry emergency service with mutism, immobility, staring, and not taking self-care for the last two months. He discontinued his medications four months back. Bush-Francis Catatonia Rating Scale (BFCRS) score was 23 at admission (Table 1). As inj. lorazepam was not available immediately, he was given tablet clonazepam 1 mg. The catatonic symptoms started improving. Within the next 2 h, the BFCRS score dropped to 8, which was maintained for the next 5 h (Table 1). At this point, he was injected lorazepam 1 mg intravenously to achieve further improvement, but BFCRS did not reduce beyond 7 even after 5 h of lorazepam as has been mentioned in Table 1. Later, the patient was interviewed and started on olanzapine 10 mg as he had earlier maintained well on it. On the next day, he was discharged with a tapering dose of clonazepam and later followed up after two weeks, when he was found to be maintaining well without any catatonic symptoms.
BFCRS Score at the Time of Initial Evaluation and on Different Intervals After Intervention (Tablet Clonazepam)
BFCRS, Bush-Francis Catatonia Rating Scale.
Discussion
Lorazepam is generally accepted as first-line because of its rapid onset of action. The onset of action is 1 min to 3 min if administered intravenously, 15 min to 20 min if given intramuscular, and 2 h if given orally. 5 There are very few studies on other benzodiazepines like diazepam and clonazepam, which were also found to be effective. Huang used a modified treatment strategy in which 14 patients with catatonic schizophrenia were treated with lorazepam 2 mg/mL intramuscular at the time of presentation in an Emergency Department, and also another 2 mg/mL intramuscular injection after 1 h if there were no response to the previous dose (trial 1). If that failed, diazepam infusion (10 mg/2 mL per ampule) in 500 mL 0.9% saline every 8 h was given for the day (trial 2). The response rates for catatonic signs were 85.7% at the end of 2 h of trial 1 and 100% at the end of the day after trial 2. It was evident that the modified treatment strategy relieved catatonic signs rapidly and completely, even without using ECT. 6 In 2017, Lin et al. also proposed the lorazepam-diazepam protocol for catatonia because of general medical conditions or substance use and showed that it could relieve catatonia within a day. 7 The use of parenteral clonazepam has been described in several case reports. In 1989, Martenyi et al. reported the effectiveness of parental clonazepam in four patients with catatonic schizophrenia. 8 In 1991, Benazzi also showed the effect of parental clonazepam in his four patients with catatonia with different primary aetiologies. 9 In 2001, Kumar showed the effectiveness of parenteral clonazepam in a young woman with acute catatonia. 10 Recently, in 2021, authors from Florida reported a case of periodic catatonia who had only a partial response with lorazepam and improved significantly with oral clonazepam. 11
The catatonia syndrome lies on a spectrum and ranges from its milder form to severe forms such as neuroleptic malignant syndrome and malignant catatonia. Treatment of catatonia should not depend merely on classic catatonic symptoms. Rather, it should always consider the cause of catatonia and associated medical comorbidities and conditions, such as excessive drowsiness, respiratory suppression, and parkinsonian symptoms. 3 Literature mentions the successful use of other agents, such as zolpidem, tofisopam, amantadine, bromocriptine, and biperiden.3,12 Most of the clinical guidelines specifically mention lorazepam instead of the broad rubric of benzodiazepines, which even constricts the alternate options in treating catatonia. 3 So, clinicians are left with only one option, failing which they often choose the second option of ECT. Long-acting benzodiazepines, like diazepam and clonazepam, might be helpful once lorazepam fails, as no comparative study describes otherwise.
Long-acting benzodiazepines with high affinity on gamma-aminobutyric acid-A receptors (GABAA receptors) (i.e., clonazepam) are potential molecules to improve catatonia in lesser frequent doses instead of multiple doses. 13 Benzodiazepines like clonazepam also have serotoninergic action on 5-hydroxytryptamine-1 (5HT1) and 5-hydroxytryptamine-2 (5HT2) receptors which modulate the GABAergic activity in the brain, which could play an additional role in treating catatonia. 14 As long-acting benzodiazepines are rarely mentioned in the literature, clinicians might not choose them in case of the unavailability of lorazepam in an emergency setting. Our case is important as it provides the rationale to use other alternative benzodiazepines in catatonia and not to limit ourselves to widely used lorazepam.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest concerning this article’s research, authorship, and publication.
Funding
The authors received no financial support for the research, authorship, and publication of this article.