Research Article: The Lorazepam and Diazepam Protocol for Catatonia Due to General Medical Condition and Substance in Liaison Psychiatry

Date Published: January 23, 2017

Publisher: Public Library of Science

Author(s): Chin-Chuen Lin, Yi-Yung Hung, Meng-Chang Tsai, Tiao-Lai Huang, Josef Priller.


The lorazepam-diazepam protocol had been proved to rapidly and effectively relieve catatonia in patients with schizophrenia or mood disorder. This study aims to investigate the efficacy of lorazepam-diazepam protocol in catatonia due to general medical conditions (GMC) and substance.

Patients with catatonia that required psychiatric intervention in various settings of a medical center were included. The lorazepam-diazepam protocol had been used to treat the catatonia due to GMC or substance according to DSM-IV criteria. The treatment response had been assessed by two psychiatrists.

Eighteen (85.7%) of 21 catatonic patients due to GMC or substance became free of catatonia after the lorazepam-diazepam protocol. Five (23.8%) of the 21 patients had passed away with various causes of death and wide range of time periods after catatonia.

Our results showed that the lorazepam-diazepam protocol could rapidly and effectively relieve catatonia due to GMC and substance.

Partial Text

Catatonia is a unique neuropsychiatric syndrome of altered consciousness and characteristic psychomotor findings. Catatonia had been associated with schizophrenia, mood disorders, general medical conditions (GMC) [1, 2], substance withdrawal [3–6], and illicit substances [7]. Catatonic patients with known history of mental disorders often receive prompt consultation from psychiatrist, but catatonia due to GMC and substance use is often managed by nonspecialist health professionals. GMC and substance constituted 20–40% of causes of catatonia [8, 9]. Therefore, the timely management of catatonia by non-psychiatrist is important, because delayed treatment can prolong recovery and lead to serious complications such as fetal pulmonary embolism and deep venous thrombosis [10–14].

From July, 1998 to July, 2014, patients with catatonia that required psychiatric consultation in emergency department (ER), intensive care unit (ICU), internal medicine ward, and surgical ward of Kaohsiung Chang Gung Memorial Hospital were recorded in a list maintained by the psychiatric staff. Some of these cases had been previously published [19, 21–23]. Medical records of catatonic patients who were treated with the lorazepam-diazepam protocol were reviewed for their catatonic symptoms and signs, treatments, treatment response, underlying etiologies, and causes of mortality. The institutional review board (IRB) of Chang Gung Memorial Hospital approved the study design of retrospective medical charts review in which no consent was required (IRB 99-2930B). Written informed consents were obtained from surviving patients who agreed to a follow-up interview, which was also approved by IRB (IRB 103-1888B).

Twenty-one patients diagnosed with catatonia due to GMC (18 patients, 85.7%) or substance-induced catatonia (3 patients, 14.3%) and treated with the lorazepam-diazepam protocol were identified (S1 Table). There were 11 males and 10 females. Their age at the time of catatonia ranged from 21 to 60 years, with a mean of 38.0 ± 10.9 years. Eighteen patients (85.7%) responded favorably with the lorazepam-diazepam protocol. Among them, fourteen (66.7%) became catatonia free after 2mg of lorazepam IMI. One patient required two injections to become catatonia free. Three patients required diazepam IVD after the initial 4mg of lorazepam IMI. Among these three, two patients’ catatonia resolved within a day, but one required more than a day. Three patients (14.3%) did not respond well. One patient received two injections of lorazepam but only had her catatonic symptoms partially relieved. Diazepam IVD was not prescribed due to her clinical condition. The other two patients showed virtually no improvement of their catatonic symptoms despite using the protocol for 24 hrs and 7 days, respectively. No obvious side effect such as respiratory suppression was observed among patients receiving the protocol.

The most important finding of the study is that the lorazepam-diazepam protocol remained effective in relieving catatonia due to GMC or substance. Of the 21 catatonic cases identified, 18 (85.7%) became free of catatonia after the benzodiazepine treatment. The response rate were slightly lower than our previously reported cases of catatonia associated with schizophrenia and mood disorder. The lorazepam-diazepam protocol had a response rate of 60 to 85% within first two hours and 85 to 100% within one day in schizophrenia [17, 18]. In catatonia associated with mood disorders, response rates of 57.1% to 66.7% within the first two hours and 100% within a day were achieved [15, 16]. It is worth noting that 14 out of 18 patients who responded with the protocol became free of catatonia after the initial 2mg of lorazepam injection. Only five out of the 21 patients were prescribed of diazepam IVD, and two of them showed no response to the treatment at all. Nevertheless, this lorazepam-diazepam protocol appeared promising in relieving catatonia due to GMC or substance effectively and rapidly.