Benzodiazepines for catatonia in people with schizophrenia or similar serious mental illness

Review question
Are the group of drugs called benzodiazepines an effective and tolerable treatment for catatonia in people with schizophrenia or other serious mental illnesses?

Background
Catatonia is a debilitating condition that is characterised by diminished, excessive or peculiar movement and activity as well as diminished engagement with the social and physical environment. It can occur when a person has a number of different psychiatric conditions, including schizophrenia (an enduring mental illness whose hallmark is an altered perception of reality); and less frequently with medical conditions. Some of the other serious mental disorders that are associated with catatonia include bipolar disorder (an illness in which there are extremes of disturbed mood) and depression (another mood disorder characterized by low mood). Benzodiazepines are widely used in the treatment of catatonia, but there is no good quality evidence from randomised controlled trials concerning their effectiveness.

Searching for evidence
The Information Specialist from Cochrane Schizophrenia ran electronic searches of the group's specialised register (the most recent in February 2019) for trials that randomised people with catatonia occurring in conjunction with schizophrenia or other similar serious mental illnesses to receive either benzodiazepines or any of the following: other drugs, placebo, or electroconvulsive therapy. One hundred and thirty records were found and checked by the review authors.

Evidence found
One trial was found in the search which met the review requirements and provided limited, very low quality usable data for one outcome only. This trial compared two benzodiazepines (lorazepam vs oxazepam) and found no clear difference between these two treatments for improvement in the symptoms of catatonia for people who have catatonia and schizophrenia or similar serious mental illness.

Conclusions
There is insufficient high quality evidence available to answer the review question. More high quality research is needed.

Authors' conclusions: 

Analysis of the results from this review, which was a head-to-head comparison of two benzodiazepine monotherapies, does not show a clear difference in effect. No data were available for benzodiazepines compared to placebo or standard care. The lack of usable data and very low quality of data available makes it impossible to draw firm conclusions and further studies with a high-quality methodology and reporting are required in order to determine more definitively the outcomes associated with benzodiazepine use in the clinical management of catatonia in persons with schizophrenia and other SMI.

Read the full abstract...
Background: 

Catatonia is a debilitating disorder of movement and volition associated with schizophrenia and some other mental illnesses. People with catatonia are more likely to require hospitalisation and highly supervised care than those without the disorder. They also have an increased risk of secondary complications such as pneumonia, malnutrition and dehydration. The mainstay of treatment has been drug therapies and electroconvulsive therapy.

Objectives: 

To compare the effects of benzodiazepines with other drugs, placebo or electroconvulsive therapy for catatonia in people with schizophrenia or other similar serious mental illnesses (SMIs).

Search strategy: 

We updated our previous search (28 February 2007) by searching the Cochrane Schizophrenia Group's Study-Based Register of Trials (9 November 2016; 6 February 2019). This register is compiled by systematic searches of major resources (including CENTRAL, MEDLINE, Embase, AMED, BIOSIS, CINAHL, PsycINFO, PubMed, and registries of clinical trials) and their monthly updates, handsearches, grey literature, and conference proceedings, with no language, date, document type, or publication status limitations for inclusion of records into the register. We also manually searched reference lists from studies selected by the search.

Selection criteria: 

All controlled clinical trials that randomised people who have schizophrenia or other similar SMI and experiencing catatonia to receive benzodiazepines or another relevant treatment. We included studies that met our inclusion criteria and reported usable data. We excluded those not meeting our inclusion criteria or those not reporting usable data. We contacted authors when we required further information; and if we received no response, we put those studies aside as 'awaiting assessment'.

Data collection and analysis: 

Review authors extracted data independently. For dichotomous data we calculated relative risks (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis using a fixed-effect model. We completed a 'Risk of bias' assessment for the included study and generated a 'Summary of findings' table using GRADE.

Main results: 

The searches found 130 citations, from which we could identify 22 possibly relevant studies. From these, we could only include one study. This study had a relatively small sample size of 17 participants who received lorazepam or oxazepam and were drug free for one week before the trial started. The only usable data reported by this study were clinically important change in symptoms of catatonia measured as 50% improvement on the Visual Analogue Scale (VAS). There was no difference in the numbers of participants showing a clinically important change in their catatonic symptoms (RR 0.95, 95% CI 0.42 to 2.16; participants = 17; studies = 1; very low quality evidence).

No data were reported for other important outcomes of hospital stay, clinically important change in satisfaction with care, global state, adverse effects or general functioning

We did find a few studies meeting our inclusion criteria but they reported no usable data. We had to exclude these. Although poorly reported, these studies do illustrate that relevant studies have been undertaken — they are not impossible to design and conduct.

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