This newsletter concisely summarizes the evidence-based consensus guideline on the management of catatonia by the British Association for Psychopharmacology, published on April 11, 2023.
We also discuss practical aspects for managing behavioral and psychological symptoms of dementia, key points from a presentation on tic disorders in children and adolescents, and our practical research summaries of adult, child, and adolescent psychiatry (Quick Takes and CAP Smart Takes).
Guidelines for Managing Catatonia: British Association for Psychopharmacology
For the first time, the British Association for Psychopharmacology has published clinical guidelines for the management of catatonia. These recommendations, which can be found in the Journal of Psychopharmacology, were developed by a global panel of experts to enhance diagnosis, research, and treatment of catatonia.
Diagnostic Criteria and Assessment for Catatonia
- Diagnosing catatonia requires at least 3 signs from DSM-5-TR or ICD-11.
- Clinical observation, interviews, physical exams, and reviewing medical records and collateral information are essential in making the diagnosis.
- The Bush-Francis Catatonia Rating Scale is the recommended scale for the assessment of catatonia.
Diagnostic Challenge Test With Lorazepam:
- Although not 100% specific, the lorazepam challenge test can confirm a diagnosis of catatonia.
- To conduct this, administer 1 mg–2 mg IV, 1 mg–2 mg IM, or 2 mg oral lorazepam and reassess catatonic features after 5 minutes (following IV lorazepam), 15 minutes (following IM lorazepam), or 30 minutes (following oral lorazepam).
- A positive response is considered a 50% reduction in score on a standardized catatonia instrument.
Summary of Pharmacologic Treatments:
- Benzodiazepines are the recommended first-line medications, followed by ECT as the second line.
- Consider clozapine for catatonia associated with schizophrenia, autism spectrum disorder, malignant catatonia, and neuroleptic malignant syndrome.
- Zolpidem may be helpful for patients with subcortical stroke whose catatonia is unresponsive to lorazepam or ECT.
Other Treatment Recommendations:
- Prompt treatment of catatonia is crucial because patients with a shorter illness duration respond better to treatment.
- Treatment must address the underlying disorder and focus on the management and prevention of complications.
- Slowly taper benzodiazepines to prevent the reemergence of catatonia.
You can read the full guideline here.
Management of Behavioral and Psychological Symptoms of Dementia, With Lauren Gerlach, D.O.
In this interview, Dr. Lauren Gerlach addresses common clinical concerns regarding the management of behavioral and psychological symptoms of dementia. She also discusses psychopharmacologic considerations when treating patients with Parkinson’s disease or Lewy body dementia with concomitant psychosis, management of apathy and mood swings, and the potential role of ECT for this population.
Interview highlights include the following:
- A key tenet in the psychopharmacologic management of behavioral and psychological symptoms of dementia is to start low and go slow, both when initiating and tapering off psychotropic medications.
- ECT may be an option for patients with comorbid depression and mild cognitive decline. Unilateral electrode placement should be tried to minimize side effects, such as memory loss.
Learn more and earn 0.5 CME credits here.
Tic Disorders in Children and Adolescents
In this presentation, Dr. David Rosenberg discusses tic disorders in youth, including an in-depth analysis of how to make a correct diagnosis, common differential diagnoses, and frequent comorbid conditions. At the end of the presentation, he highlights essential clinical pearls through a case example.
Tic Disorders and Psychiatric Comorbidities
- Decreased response rates to SSRIs have been observed in children with tic-related OCD.
- CBT is considered the first-line treatment for tic-related OCD.
- Depression is associated with earlier onset, greater severity, and longer duration of tics.
- Irritability, mood instability, and emotional dysregulation are common in youth with tic disorders.
Learn more and earn 1.5 CME credits here.
Quick Takes: Research, Digested
Associations Between Antipsychotic Use, Substance Use, and Relapse Risk in Patients With Schizophrenia
- Among patients with a diagnosis of schizophrenia, treatment with clozapine was associated with a decreased probability of developing a substance use disorder.
- In an earlier small randomized trial, among patients who use cannabis regularly, clozapine appears to suppress craving induced by viewing cannabis-related images—more so than with risperidone. Learn more.
Listen to or read the full volume, and earn 0.5 CME credits here.
CAP Smart Takes: Research, Digested
Risk of Cardiovascular Diseases Associated With Medications Used in ADHD
- The potential risk of cardiovascular events associated with ADHD medications seems to be elevated in patients with preexisting cardiovascular conditions, although this observation is not statistically significant.
- It is crucial to monitor vital signs at baseline and each visit for patients on ADHD medication, with added caution for those with preexisting cardiovascular conditions. Learn more.
Listen to or read the full volume, and earn 0.5 CME credits here.
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References
- Rogers, J. P., Oldham, M. A., Fricchione, G., Northoff, G., Ellen Wilson, J., Mann, S. C., Francis, A., Wieck, A., Elizabeth Wachtel, L., Lewis, G., Grover, S., Hirjak, D., Ahuja, N., Zandi, M. S., Young, A. H., Fone, K., Andrews, S., Kessler, D., Saifee, T., Gee, S., … David, A. S. (2023). Evidence-based consensus guidelines for the management of catatonia: Recommendations from the British Association for Psychopharmacology. Journal of Psychopharmacology, 37(4), 327–369.
