Midazolam in the treatment of catatonia: A case series

Catatonia is a condition estimated to affect 10% to 15% of patients admitted to psychiatric hospitals. It is characterized by motor and behavioral changes including staring, mutism, changes in muscle tone such as waxy flexibility, posturing, and changes in movement patterns. Benzodiazepines are considered a first-line treatment option for catatonia, and most people achieve symptom remission within days. Most literature supports use of lorazepam for treatment of catatonia, and there is limited data about use of other benzodiazepines such as midazolam.

Here we report a 6-person case series of patients admitted to an inpatient psychiatric unit with catatonia and treated at least in part with midazolam. We describe the safety outcomes such as respiratory depression, hypotension, and bradycardia, as well as the effectiveness of treatment. In this case series, all patients were treated with midazolam with or without other benzodiazepines and/or electroconvulsive therapy (ECT) during their inpatient stay for catatonia. Overall, these 6 patients tolerated doses of intravenous (IV) midazolam ranging from 4 to 32 mg daily and up to 48 mg daily of oral midazolam. There were no clinically relevant episodes of respiratory depression, hypotension, or bradycardia. Midazolam appeared to be at least partially effective as an adjunctive therapy in 5 of the 6 cases, but vast improvement was seen after ECT initiation.

Midazolam may be an alternative or adjunctive therapy for the treatment of catatonia in circumstances where IV lorazepam is unavailable. More rigorous studies should be performed to more clearly elucidate the safety and effectiveness of midazolam as monotherapy and when used in combination with ECT early in the treatment of catatonia.