Comparison of International Therapy Guidelines with Regard to the Treatment of Malignant Catatonia

Abstract

Objective Malignant catatonia (MC) is an extremely rare, life-threatening disorder. It is characterized by catatonic symptoms accompanied by autonomic instability, hyperthermia, and changes in laboratory values. In many cases, MC is not recognized as such. Evidence-based guidelines are essential to ensure quality of treatment, but what do current national and international guidelines recommend? Method Online search for international guidelines from English-, French-, Italian-, and German-speaking countries whose medical care meets high standards addressing the treatment of MC. These were analyzed and compared regarding statements on MC, recommendations, and strength of scientific evidence. Results Fifteen of the identified guidelines were included. Only 5 of 15 comment on the treatment of MC. As for other rare diseases, no detailed recommendations are available. Suggested therapies are limited to benzodiazepines and electroconvulsive therapy. Levels of evidence and grades of recommendation are predominantly low. Conclusion Many international guidelines do not mention MC. It is not possible to derive a clear algorithm for the treatment of MC from most current guidelines. A thorough update of most guidelines appears to be necessary. Lack of awareness and knowledge of MC among physicians and medical professionals might lead to inadequate or delayed care, worsened outcome, or death.

Treatment of the Neuroleptic Malignant Syndrome in International Therapy Guidelines: A Comparative Analysis

“…Our research shows that the NMS therapy recommendations in international guidelines are (if any are reported) very heterogeneous, partly inconsistent, and of poor evidence, a fact that is not uncommon in the field of rare diseases [53]. This peculiarity makes it difficult to deduce the best possible treatment strategy from the analyzed guidelines.…”

Evidence-based consensus guidelines for the management of catatonia: Recommendations from the British Association for Psychopharmacology

“…Since RCTs are unavailable, treatment recommendations for malignant catatonia are based on case reports or case series. Five international guidelines for the management of schizophrenia specifically address the treatment of malignant catatonia ( Schönfeldt-Lecuona et al, 2020a ), although they are based on low levels of evidence. Each of the guidelines recommends ECT either as the initial treatment or as second line after a failed benzodiazepine trial.…”

“…A series of international guidelines for the management of schizophrenia contain certain specific recommendations for the treatment of NMS, but these are based on weak levels of evidence and do not consider all relevant treatment options (Schönfeldt-Lecuona et al, 2020a). Schönfeldt-Lecuona et al (2020a) contend that expert-based treatment algorithms derived from clinical experience, numerous clinical reports and rational theories are of greater value than recommendations provided by the guidelines. These algorithms stress that the specific treatment of NMS be individualised and based on the character, duration and severity or stage of clinical features (Caroff et al, 2022;Davis et al, 2000;Strawn et al, 2007;Woodbury and Woodbury, 1992).…”