Catatonia is an underrecognized neuropsychiatric syndrome affecting approximately 10% of individuals hospitalized on inpatient psychiatric units. First-line treatments for this condition include benzodiazepines (BZD) and/or electroconvulsive therapy (ECT). However, 20-40% of individuals do not respond to BZD alone and ECT is not always accessible. Second generation antipsychotics (SGA) have been used to treat catatonia in these circumstances. Here, we review the literature pertaining to the efficacy and safety of SGA in the treatment of catatonia.

We conducted a PubMed search for articles linking catatonia to antipsychotics, under the search heading “catatonia” or “kahlbaum” and “risperidone”, “amisulpride”, “iloperidone”, “olanzapine”, “aripiprazole”, “paliperidone”, “clozapine”, “brexpiprazole”, or “cariprazine”. Reports commenting on SGA treatment efficacy and/or their role in the development of catatonia were included in the analysis. Selected articles were reviewed for patient demographics, psychiatric/medical history, symptoms, cause of catatonia and treatment, and co-administered agents. For each SGA, we calculated the number of cases in which catatonia was likely improved with antipsychotic treatment, and the number of cases in which catatonia was precipitated or worsened with antipsychotic treatment (improved/worsened ratio). Case data was assessed using the Naranjo Adverse Drug Reaction Probability Scale. Descriptive statistics were used to analyze the data.

At the time this abstract was written, we reviewed 480 of the original 507 articles. One hundred and seventeen of the 480 met inclusion criteria. There was one randomized controlled trial (RCT), five prospective studies, four retrospective studies and 107 case reports. Of all reviewed literature quetiapine (34:3, 92%), aripiprazole (16:2, 89%), amisulpride (18:1, 95%), andclozapine (19:1, 95%) had the highest improved/worsened ratio, conversely paliperidone (0:5, 0%) had the lowest improved/worsened ratio.

Of the available literature quetiapine, amisulpride, aripiprazole, and clozapine were found to be relatively safe andeffective as treatment options in catatonia, while palipderidone was found to have reports pointing to its role in the development/worsening, but none on the improvement, of catatonia. These results need to be interpreted with caution. In the majority of cases where SGA’s were effective, patients were co- treated with other pharmacologic agents (most frequently benzodiazepines), making it difficult to assess the role of the antipsychotic alone. Also, given that the preponderance of studies were case reports, publication bias may be an important limitation. Further studies are needed to examine the safety and efficacy of SGA in treating catatonia.

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