Table 1.

Cases of Catatonia Associated With the SARS-CoV-2 Pandemic

Reference	Age, gender, location	Psychiatric symptoms	Nonpsychiatric COVID-19 symptoms	Psychiatric history	Medical history	Serum inflammatory markers	Initial treatment	Clinical course/outcome	Potential sources of bias
Present case (Ms. A)	Early 50s, Female, USA	Stupor, mutism, staring, mundane posturing, negativism, withdrawal, self-harm by laceration BFCRS score 11	Myalgia and fatigue 11 d before presentation, resolved by time of presentation	None	HTN, osteoarthritis SARS-CoV-2 infection	WBC count 14 × 109 cells/L, LDH 292 U/L, CRP 13.9 mg/L	Lorazepam 2 mg IV once with lysis of catatonia (BFCRS = 0) after 45 min	Lorazepam 1 mg PO q8 h for 7 d and then changed to clonazepam 0.5 mg PO daily and discontinued at 3-wk follow-up appointment; mirtazapine 30 mg PO nightly; melatonin 6 mg PO nightly No recurrence of symptoms at 5 wk.	Ascertainment – No CSF studies
Present case (Ms. B)	Early 50s, Female, USA	Withdrawal, mutism, staring, negativism BFCRS score 12	Diarrhea	Schizophrenia, disorganized type, without catatonic features	Cerebrovascular infarct, age indeterminant, esophageal rupture SARS-CoV-2 infection	WBC count 19.8 × 109 cells/L, LDH 385 U/L, CRP 45.9 mg/L, D-dimer 7433 ng/mL	Valproic acid 500 mg IV BID Lorazepam 2 mg IM once with lysis of catatonia (BFCRS = 2) after 1 h	Lorazepam 2 mg PO q8 h, tapered and discontinued on day 14; olanzapine 10 mg PO nightly; Extended-release valproic acid 250 mg PO BID Multiple ED presentations for medical complaints over several months, no apparent catatonic symptoms	Ascertainment – No CSF studies Causality – Underlying SMI. – Other medical illness – Use of medications which may provoke psychosis
Present case (Ms. C)	Early 20s, Female, USA	Stupor, mutism, mundane posturing, rigidity, negativism, echopraxia, withdrawal, paranoia, pseudocyesis BFCRS score 14	None	Bipolar disorder, type 1, MRE manic	SARS-CoV-2 infection	None	Lorazepam 2 mg IM once with lysis of catatonia (BFCRS = 3) and residual agitation, perseverative speech	Lorazepam 3 mg PO TID, reduced to 1.5 mg PO TID by discharge on HD#10; Lithium 1500 mg PO nightly; Aripiprazole 10 mg PO daily Catatonic symptoms resolved by discharge, lost to follow-up.	Ascertainment – No CSF studies Causality – Underlying SMI.
Caan et al., 202012	43, Male, USA	Anxiety, withdrawal, response to internal stimuli, rigidity, mutism, posturing, auditory hallucinations, paranoia. BFCRS not reported on initial examination. Authors note likely severity score of 12.	Fever, tachycardia, cough 15 d prior to catatonic episode Diaphoresis on presentation for catatonia	None	SARS-CoV-2 infection	Platelet count 551 TH/μL	Lorazepam 1 mg IV TID	Lorazepam tapered to 1 mg PO BID by discharge on HD#10; No recurrence of catatonic symptoms as of post-discharge day #6. Residual anhedonia, sadness, insomnia treated with lorazepam 1 mg PO nightly and 6 mg melatonin nightly.	Ascertainment – No CSF studies
Gouse et al., 202013	Elderly, Male, USA	Mutism, staring, posturing grimacing, echolalia, verbigeration, stereotypy, rigidity, waxy flexibility, automatic obedience BFCRS score 18	Fatigue, headache, hypoxia, fever, progressing to hypoxic respiratory failure and death on HD#7	Schizophrenia	COPD, interstitial lung disease, DM2, HTN, atrial fibrillation, essential tremor SARS-CoV-2 infection	Ferritin 1400 ng/mL, CRP 85.20 mg/L, D-dimer 1200 ng/mL, LDH 600 U/L, Pro-calcitonin > 0.3 ng/mL	Lorazepam 1 mg IV with improvement of catatonia (BFCRS = 9)	Lorazepam 1 mg IV TID, reduced to 0.5 mg IV TID due to worsening respiratory failure Patient expired on HD#7.	Ascertainment – No CSF studies Causality – Underlying SMI. – Other medical illness
Zandifar and Badrfam, 202014	61, Male, Iran	Auditory hallucinations, Capgras delusion, paranoia progressing to mutism, stupor, posturing, negativism, rigidity BFCRS score not reported	Lethargy, nausea, seizure. Hyponatremia (Na 120 mg/L)	Schizophrenia	SARS-CoV-2 infection	WBC count 15.7 × 109 cells/L	Prior to catatonic symptoms: haloperidol 10 PO daily, biperiden 3 mg PO daily; medications held at time of catatonia diagnosis Lorazepam 2 mg PO TID	Authors do not report whether lorazepam was continued on discharge; restarted on haloperidol 10 mg PO daily, biperiden 3 mg PO daily; resolution of catatonia after 24 h. Authors note a marked reduction in psychiatric symptoms at discharge.	Ascertainment – No CSF studies – BFCRS not used Causality – Underlying SMI – Other medical illness
Amouri et al., 202015	70, Female, USA	HD#3 – confusion HD#4- somnolence, disorientation, confusion which continued through HD#12. HD#12 – immobility, mutism, grimacing, catalepsy, echolalia, stereotypy, verbigeration, rigidity, negativism, waxy flexibility, automatic obedience, gegenhalten BFCRS score 21	Five day history of cough, fatigue, fever. Hospital course complicated by acute hypoxemic respiratory failure, NSTEMI, physical deconditioning, fever, delirium.	None	End-stage renal disease, DM2, HTN, Coronary artery disease, NSTEMI, heart failure with preserved ejection fraction, hypothyroidism, TIA SARS-CoV-2 infection	Inpatient laboratory results not reported in detail. Blood cultures noted to be negative.	Lorazepam 0.5 mg IM with improvement in catatonia (BFCRS = 12).	Lorazepam 0.5 mg PO or IV q8 h, tapered to 0.5 mg PO or IV BID, discontinued by HD #16; “Broad spectrum antibiotics” from HD#5-HD#8; Catatonic symptoms improved Patient discharged to rehabilitation facility.	Ascertainment – No CSF studies Causality – Underlying SMI. – Other medical illness
Deocleciano de Araujo et al., 202016	50, Male, Brazil	Disorganization, rigidity, negativism, withdrawal. BFCRS score not reported.	Fever, Tachypnea, tachycardia, hypoxia. Course complicated by aspiration pneumonia.	Intellectual disability, mild	Childhood epilepsy SARS-CoV-2 infection	CK 8819 U/L, WBC count 20.8 × 109 cells/L, Platelet count 544,000 mm3/L	Pneumonia treatments: Azithromycin, amoxicillin/clavulanate, piperacillin/tazobactam, meropenem, vancomycin, dexamethasone 6 mg daily Diazepam 10 mg IV QID with poor response; switched to lorazepam 2 mg PO TID on HD#4	Sertraline 25 mg PO daily and olanzapine 5 mg PO daily added on HD #18. Transferred to psychiatry unit for ECT on HD#19. Received bilateral stimulus at 30% with immediate partial response (improved mutism). Remission after 10 sessions. Discharged after 50 d with unspecified dose of sertraline and olanzapine.	Ascertainment – BFCRS not used Causality – Other medical illness – Use of medications which may provoke psychosis
Sarli et al., 202017	59, Male, Italy	Anxiety, depression, hopelessness, anhedonia, apathy, anorexia, insomnia, delusion of pauperization, mutism, stupor, waxy flexibility. BFCRS score not reported.	Patient was not diagnosed with SARS-CoV-2 infection	None	None	Inpatient labs not reported.	Lorazepam 4 mg “vial” (route not specified, presumably IM or IV), olanzapine 5 mg. Response not reported.	Lorazepam tapered to 2.5 mg PO nightly, olanzapine increased to 7.5 mg PO nightly, and sertraline 100 mg PO daily. The patient was noted to have “slow improvement.”	Ascertainment – BFCRS not used Causality – Patient was not diagnosed with SARS-CoV-2 infection.
Huarcaya-Victoria et al., 202018	23, Female, Peru	Anxiety, insomnia, religious delusions, delusions of reference, auditory hallucinations, agitation, impaired attention, stereotypy, catalepsy, verbigeration. BFCRS score not reported.	Fever	None	SARS-CoV-2 infection	Platelet count 329,000 mm3/L	Midazolam IV at an outside facility with “little effect,” ziprasidone 40 mg (route and frequency not reported)	Olanzapine 15 mg PO daily Patient had “remission of psychotic symptoms.”	Ascertainment – No CSF studies – BFCRS not used Causality – Typical catatonia challenge protocol not used Reporting – Clinical course not described in detail
Varatharaj et al., 202019	“One patient with catatonia”, UK	Case details not available.	Not reported	Not reported	SARS-CoV-2 infection	Not reported	Not reported	Not reported	Reporting – No case details available; high risk of bias

BFCRS = Bush-Francis catatonia rating scale; BID = twice daily; COPD = chronic obstructive pulmonary disease; CRP = C-reactive protein; CSF = cerebrospinal fluid; DM2 = diabetes mellitus, type 2; ECT = electroconvulsive therapy; HD = hospital day; HTN = hypertension; IM = intramuscular; IV = intravenous; LDH = lactate dehydrogenase; MRE = most recent episode; Na = sodium; NSTEMI = non-ST elevation myocardial infarction; PO = per mouth; QID = 4 times daily; SMI = serious mental illness; TIA = transient ischemic attack; TID = 3 times daily; WBC = white blood cell.