Catatonia Crisis: Navigating the IV Lorazepam Shortage

Due to increased demand, manufacturing delays, and disruption of the manufacture of the drug, there is a current shortage of intravenous (IV) lorazepam (Ativan). This has led to a disruption in psychiatric care, particularly for patients in the emergency department setting who are experiencing catatonia. This shortage, although troubling for some psychiatric clinicians, may be a symptom of a much larger problem. ^1,2

Drug Shortages

As of November 7, the US Food and Drug Administration (FDA) listed 76 drugs as being in shortage. Of those, 14 are related to psychiatry (Figure). Several are attention-deficit/hyperactivity disorder treatments.³

During the past 5 years, partly because of the COVID-19 pandemic, inspections of pharmaceutical production plants ground to a halt. Now, the FDA is struggling to catch up, particularly with a proliferation of so-called “quality problems.”^4,5

“Injectable lorazepam [Ativan], both [IV] and intramuscular [IM], has been in shortage since 2021, with issues related to one manufacturer stopping production and others having a shortage due to increased demand. The COVID-19 pandemic also had an impact on the shortage from increased use of lorazepam for sedation during intubation of patients, and we have not recovered from this yet,” said Danae N. DiRocco, MD, medical director for consultation-liaison psychiatry at CHI Health and assistant clinical professor at Creighton University.

Trade tariffs, particularly those on China, have placed further strain on the pharmaceutical supply chain, as more than 92% of the facilities that manufacture US generic pharmaceuticals are overseas. Notably, a large portion of the global supply of active ingredients for medications comes from China.⁶

“Losing a treatment option for serious psychiatric and medical conditions can severely impact patient outcomes, especially where other evidence-based options are not readily available, like with catatonia,” DiRocco said. “It leads health care systems, pharmacies, and providers to make hard choices about how to allocate this treatment and to whom.”

Lorazepam is a widely prescribed benzodiazepine that is used to manage several symptoms off-label, including agitation, aggression, alcohol withdrawal, panic disorder, and catatonia. It bypasses phase 1 metabolism with no active metabolites, is safer to use in patients with hepatic impairment, presents a lower risk of some adverse reactions, and has fewer drug-drug interactions than other benzodiazepines, making it the drug of choice for many clinicians.⁷ Unfortunately, lorazepam has been in short supply off and on at least 3 times over the past 2 decades, with a median shortage duration of 1436 days.⁸

“The major problem that has occurred with the shortage is that there is nothing quite like Ativan [lorazepam]. It gets into the brain slower than some of the other drugs, but it also stays in the brain longer than some of the other drugs, and that is because it is not as lipid soluble as drugs like diazepam [Valium] or midazolam [Versed]. Therefore, Ativan [lorazepam] has advantages over all the other drugs,” said Phillip R. Muskin, MD, senior consultant in consultation-liaison psychiatry at NewYork-Presbyterian Hospital and Columbia University Medical Center, and Psychiatric Times editorial board member. “The problem with the loss of the drug, because it is in such shortage, is that now we have to use drugs that we do not have the same experience with, particularly for the treatment of catatonia.”

An Increase in Rates of Catatonia

Catatonia, an increasingly commonly recognized syndrome in critical illness, is frequently underreported.⁹ However, psychiatric clinicians are reporting an increase in rates of catatonia seen in emergency settings.

According to recent research, there is a US catatonia-related hospitalization prevalence rate of 5.15 (95% CI, 5.08-5.23) per 100,000 individuals.¹⁰ In acute inpatient psychiatric settings, the prevalence of catatonia ranges from 9% to 20%.^11-13

“There has been an enormous increase in patients with catatonia and anxiety,” said Horacio Capote, MD, medical director of the Division of Neuropsychiatry at Dent Neurologic Institute, medical director of addiction services at BryLin Hospital, and Psychiatric Times editorial board member. “I can imagine that this is a postpandemic phenomenon.”

One study showed that there is a particularly high prevalence of catatonia in certain illnesses, including depressive and bipolar disorders, with up to 20% of patients with an acute manic episode exhibiting classic catatonic signs.¹⁴

“Injectable lorazepam is an important medication in the treatment of catatonia and alcohol withdrawal, as well as a treatment for acute agitation in medical settings. Many pharmacies are limiting the use of Ativan [lorazepam] due to these shortages,” DiRocco said. “Although other treatment options exist and are effective for alcohol withdrawal and for agitation, Ativan [lorazepam] has been the mainstay of catatonia treatment, and injectable forms are especially important when a patient is too impaired to safely swallow pills.”

The loss of a drug that can adequately address catatonia can thus have a severe impact on patients, as echoed by several members of the Psychiatric Times Editorial Board.

“The Ativan [lorazepam] shortage has impacted my colleagues and my ability on the consult-liaison service to recommend Ativan [lorazepam] for individuals with various medical complexities, especially catatonia,” said Frank A. Clark, MD, an outpatient psychiatrist at Prisma Health-Upstate and clinical associate professor at the University of South Carolina School of Medicine Greenville.

“The lorazepam challenge has impacted psychiatry hospital services significantly. We see the biggest impact on catatonia cases, where lorazepam is the standard of care,” said Nidal Moukaddam, MD, PhD, a professor in the Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine, director of psychiatry outpatient services at Harris Health, and medical director of the Stabilization, Treatment & Rehabilitation Program for Psychosis.

Alternative Solutions: Recommendations From Clinicians

“The literature is replete with evidence showing that Ativan [lorazepam] is the preferred and most well-studied benzodiazepine for treating patients with catatonia,” Clark shared. However, when it is unavailable, what solutions can practicing clinicians turn to?

Psychiatric Times asked experts to offer advice on the best alternatives to lorazepam, or what they have been using in the wake of this shortage. Here are the responses:

• Talk with your pharmacy and hospital leadership about what supplies of IM, IV, and oral lorazepam are like in the place you practice. Maintain open communication regarding supply issues, as these are likely to change regularly. Determine how to prioritize the use of this medication in your setting so that short supplies can be applied to the areas of most need. Ensure all teams using injectable lorazepam for all its possible indications, including medical specialties such as intensivists, anesthesiologists, and neurologists, know about and are using alternative treatments for conditions like alcohol withdrawal, status epilepticus, catatonia, sedation during intubation, and agitation so that supplies can be protected and used when most needed.
• A close alternative suggested by pharmacies is midazolam.⁷ However, as it has a shorter half-life than lorazepam, more frequent dosing may be required, and the improvement in catatonia has not been as consistent. We have sought other psychotropic agents with different mechanisms of action, but, of course, these are not as effective.
• Midazolam can be effective given its rapid onset of action. However, given its shorter half-life compared with lorazepam, its benefits for sustained management of catatonia are not as robust. Higher dosing and frequency of dosing are increased with midazolam due to its short duration of action.
• Seek an exception for catatonia. For other uses, stay close to pharmacy colleagues to discuss improvised alternatives, considering relative doses and half-lives.
• Become familiar with 1 or 2 other benzodiazepines that are reasonable options to use in place of lorazepam, and use these to become comfortable with their clinical effects.
• Electroconvulsive therapy (ECT) is another effective treatment for catatonia. Hence, the issue is markedly problematic in parts of the US where ECT is not easy to access. In states where ECT is accessible, use ECT as a next step if lorazepam is unavailable or if the patient does not respond.

“More research into alternative treatments for catatonia, if the Ativan [lorazepam] shortage remains a long-term issue, is warranted,” DiRocco said.

References

1. Current drug shortages: lorazepam injection. American Society of Health-System Pharmacists. September 18, 2025. Accessed November 10, 2025. https://www.ashp.org/drug-shortages/current-shortages/drug-shortage-detail.aspx?id=87 https://www.ashp.org/drug-shortages/current-shortages/drug-shortage-detail.aspx?id=87 https://www.ashp.org/drug-shortages/current-shortages/drug-shortage-detail.aspx

2. Drug shortage report for Ativan. Drug Shortages Canada. October 18, 2025. Accessed November 10, 2025. https://www.drugshortagescanada.ca/shortage/263700

3. FDA drug shortages. FDA. Accessed November 10, 2025. https://www.accessdata.fda.gov/scripts/drugshortages/default.cfm

4. FDA. Report on the State of Pharmaceutical Quality. Center for Drug Evaluation and Research Office of Pharmaceutical Quality. 2024. Accessed November 10, 2025. https://www.fda.gov/media/188153/download?attachment

5. Quaglia S. 'An urgent public health crisis': why so many people are struggling to get medicine. BBC. October 22, 2025. Accessed November 10, 2025. https://www.bbc.com/future/article/20251021-why-youre-having-trouble-getting-your-meds

6. Socal MP, Dada M, Dai T. Prescription for made in America? tariffs and US drug manufacturing. Health Aff Sch. 2025;3(7):qxaf122.

7. Liu TT, Frost ED, Donlon J, et al. Surge of midazolam use in the midst of lorazepam shortage. J Clin Psychopharmacol. 2023;43(6):520-526.

8. Whitledge JD, Fox ER, Mazer-Amirshahi M. Benzodiazepine shortages: a recurrent challenge in need of a solution. J Med Toxicol. 2022;19(1):4-6.

9. Saddawi-Konefka D, Berg SM, Nejad SH, Bittner EA. Catatonia in the ICU: an important and underdiagnosed cause of altered mental status. a case series and review of the literature*. Crit Care Med. 2014;42(3):e234-241.

10. Luccarelli J, Smith JR, Kalinich M, et al. The population-based incidence and prevalence of catatonia. J Neuropsychiatry Clin Neurosci. 2025;37(2):160-162.

11. Rosebush PI, Hildebrand AM, Furlong BG, Mazurek MF. Catatonic syndrome in a general psychiatric inpatient population: frequency, clinical presentation, and response to lorazepam. J Clin Psychiatry. 1990;51(9):357-362.

12. Lee JW, Schwartz DL, Hallmayer J. Catatonia in a psychiatric intensive care facility: incidence and response to benzodiazepines. Ann Clin Psychiatry. 2000;12(2):89-96.

13. Wilson JE, Oldham MA, Francis A, et al. Catatonia: American Psychiatric Association Resource Document. J Acad Consult Liaison Psychiatry. 2025;66(4):277-299.

14. Abrams R, Taylor MA, Coleman Stolurow KA. Catatonia and mania: patterns of cerebral dysfunction. Biol Psychiatry. 1979;14(1):111-117.