Thursday, January 18, 2018

Catatonia Often Goes Undiagnosed, Untreated in General Hospitals

Physicians fail to diagnose the majority of cases of catatonia in a general hospital setting, which may result in suboptimal treatment for these patients, according to an article in the Journal of Neuropsychiatry and Clinical Neurosciences. However, psychiatric consultation can significantly decrease the odds of failure to diagnose the condition, the study found.

Diagnosing catatonia is challenging because it requires clinical suspicion and physical examination, according to researchers Joan Roig Llesuy, M.D., of New York University School of Medicine and colleagues. While catatonia is often reversible when treated with lorazepam and/or electroconvulsive therapy (ECT), its underrecognition and subsequent lack of treatment might lead to dangerous medical complications, the authors wrote.

Moreover, failure to recognize catatonia may lead to improper treatment with antipsychotics, which can increase the risk for developing malignant catatonic features or neuroleptic malignant syndrome. “Thus, awareness about catatonia for all clinicians is relevant to improve patient care,” the authors wrote.

The study involved a retrospective chart review of adult inpatients at the University of Chicago general hospital between 2011 and 2013. The presence of three or more keywords in the chart describing catatonia-related signs was used to flag cases for review. Of 133 cases found meeting DSM-5 criteria for catatonia, 79 (nearly 60%) were not diagnosed with the condition.

Additional analysis revealed that patients meeting DSM-5 criteria for catatonia who underwent a psychiatric consultation during the admission process were more than 44 times as likely to be correctly diagnosed with catatonia, compared with those who did not receive a consultation. Still, more than one-third of undiagnosed patients (37%) had received a psychiatry consult, supporting “the need for greater recognition of catatonia across disciplines,” the researchers wrote.

Physicians may be unaware of the cluster of signs and symptoms that constitute catatonia: the presence of grimacing, agitation, or echolalia symptoms was associated with a 4 to 6 times greater likelihood that the catatonia would go undiagnosed.

Regardless of diagnosis of catatonia, none of the 133 subjects received ECT. Also, no differences were found in the rate of lorazepam treatment between diagnosed or undiagnosed patients: half of those with catatonia did not receive lorazepam. However, the total dose of lorazepam was significantly lower in the undiagnosed group, who received 0.4 mg a day on average versus those diagnosed with catatonia, who received an average of 1.3 mg a day. High doses of lorazepam for several days or longer might be needed to treat catatonia effectively, the researchers wrote.

“Improving detecting and treatment of catatonia could help improve clinical outcomes of patients with this reversible syndrome in the general hospital,” concluded the authors.

For related information, see the Journal of Neuropsychiatry and Clinical Neurosciences article “Suspected Delirium Predicts the Thoroughness of Catatonia Evaluation.”

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