|Year : 2016 | Volume
| Issue : 2 | Page : 99-104
Health workers' opinion about catatonia in a Nigerian tertiary health facility
Aghukwa Nkeremadu Chikaodiri, Musa Gambo Takai
Department of Psychiatry, Aminu Kano Teaching Hospital, Kano, Nigeria
|Date of Web Publication||1-Aug-2016|
Musa Gambo Takai
Department of Psychiatry, Aminu Kano Teaching Hospital, PMB 3452, Kano
Source of Support: None, Conflict of Interest: None
Background: Catatonia is a clinical syndrome that appears in many psychiatric and medical illnesses, yet most clinicians globally tend to view it as a purely psychiatric disorder. Aim: The aim of the present study was to determine the clinicians' ability and to identify patients with catatonia. Setting: This study was conducted in Aminu Kano Teaching Hospital, Kano, Nigeria. Methods: The study was a descriptive and cross-sectional study that interviewed randomly selected 252 clinical staff comprising of doctors, nurses and physiotherapists. A pilot tested, researcher designed self-administered questionnaire was used to elicit the participants' sociodemographic information as well as their ability to identify catatonia. Results: Of 252 respondents, 120 (47.6%) were males and 132 (52.4%) were females. The mean age of the respondents was 35.9 ± 7.61 years. The majority of the respondents 172 (68%) had at least 5 years of working experience. Large proportion 215 (85%) of health professionals in this study identified catatonia as a type of mental illness. About one-third of the participants, i.e., 87 (35%) were able to identify the condition as catatonia whereas majority, i.e., 155 (62%) identified the condition as schizophrenia. A large proportion 168 (67%) of the health workers despite their years of professional experience thought catatonia was a disorder for only psychiatrists. Conclusions: The study shows that majority of health professionals with prime role in patients' care had difficulty detecting catatonia. Most of them viewed catatonia as a mental illness that should be treated by a psychiatrist. This underscores the need to plan an enlightenment program on identification and management of patients with catatonia among clinicians in Nigeria.
Keywords: Catatonia, health workers, hospital, opinion
|How to cite this article:|
Chikaodiri AN, Takai MG. Health workers' opinion about catatonia in a Nigerian tertiary health facility. Niger J Basic Clin Sci 2016;13:99-104
|How to cite this URL:|
Chikaodiri AN, Takai MG. Health workers' opinion about catatonia in a Nigerian tertiary health facility. Niger J Basic Clin Sci [serial online] 2016 [cited 2021 Dec 2];13:99-104. Available from: https://www.njbcs.net/text.asp?2016/13/2/99/181230
| Introduction|| |
Catatonia is a syndrome of motor presentations that appear in many identifiable psychiatric and medical illnesses., Despite the manifestation of catatonia in a wide range of medical, neurological and psychiatric disorders, it tends to be seen as a purely psychiatric disorder by clinicians. There are more than two dozen signs of catatonia some of which are mutism, stupor, posturing, negativism, echo-phenomena and speech abnormalities, waxy flexibility, automatic obedience and ambitendency., Other nonspecific features such as excitement, mannerisms and stereotypies, reduced functioning (loss of skills such as toileting, ability to feed or dress) may present in catatonia., Catatonia responds more to treatment with benzodiazepines and electroconvulsive therapy (ECT) rather than antipsychotics; these features support the categorisation of catatonia as an independent syndrome.,
Taking into account the current scientific evidence, the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) made several changes in the classification of catatonia., Four changes are, therefore, made in the treatment of catatonia in DSM-5. A single set of criteria will be utilised to diagnose catatonia across the diagnostic manual and catatonia will be a specifier for both schizophrenia and major mood disorders. In addition, catatonia will also be a specifier for other psychotic disorders, including schizoaffective disorder, schizophreniform disorder, brief psychotic disorder and substance-induced psychotic disorder. A new residual category of catatonia not otherwise specified will be added to allow for the rapid diagnosis and specific treatment of catatonia in severely ill patients for whom the underlying diagnosis is not immediately available.,
The advent of antipsychotics and a decline in prevalence of infectious diseases saw a decline in the diagnosis of cases of catatonia, especially in the Western world. However, catatonia may not be uncommon, rather underdiagnosed in general medical practice due to poor visibility of identification by clinicians., The concept of catatonia was initially linked to schizophrenia, but it was later found in mood, conversion and organic mental disorders., It has been associated with various other conditions that are not direct consequences of psychological dysfunctions such as temporal lobe epilepsy due to cortical and subcortical glutamatergic dysfunction, drugs (prescribed and recreational), metabolic disorders, general medical conditions (such as HIV, syphilis), brain injuries and tumors, severe childhood infections/deficits in fetal cortical development, obstetric disorders and sometimes idiopathic where no cause is identified., Dopaminergic blockade by antipsychotics could induce a form of catatonia regarded as neuroleptic malignant syndrome (NMS), which could be lethal if not carefully treated after identification. On the other hand, sudden withdrawal of clozapine which is an atypical antipsychotic could precipitate NMS due to cholinergic/serotonergic rebound hyperactivity.
Management of catatonia most times is a medical in-patient care that needs intensive nursing and monitoring of the patient's vital signs. Benzodiazepines are effective in the treatment of acute catatonia. The motor symptoms of acute catatonia probably occur due to a deficiency of cortical gamma-amino butyric acid (GABA). Benzodiazepines increase GABA activity, which could explain their therapeutic effect in catatonia. Some patients with chronic catatonia require higher doses of lorazepam administered for long durations.,, Both unilateral and bilateral ECT are effective in the treatment of chronic catatonia and should be considered as a treatment option in patients who did not respond to benzodiazepines., Secondary line treatment in case of non-responsiveness to the earlier measures could be with mood stabilisers (such as carbamazepine), antipsychotics (risperidone), N-methyl D-aspartate antagonist (amantadine), dopamine agonists (bromocriptine) and skeletal muscle relaxants (dantrolene) if the NMS is suspected.
The patient's physical condition may necessitate the use of intravenous and parenteral fluids, close monitoring of electrolytes, renal functions and other applicable indices. Also, physiotherapy and Intensive care may be warranted in patients with or without NMS. Psychiatric in-patient care is usually ideal in patients with excitement while liaison consultations are better in such patients when the excitement coexists with underlying medical problems that need astute management.
Studies have shown that health workers in Nigeria do not have favourable attitudes toward patients with perceived mental illness and as a result, many would not wish to be involved in their care., Catatonia as with epilepsy represents one of the clinical syndromes where both psychiatrists and neurologists work hand in hand, but an understanding of this perception has not been investigated among health workers in Nigeria. This study, which is the first known to the author in the present place, aimed to examine the health workers' ability to identify catatonia and, also, their opinion toward the care of such patients. The outcome of this study would help in planning an awareness program on identification and management of patients with catatonia for them.
| Methods|| |
The research was conducted in Aminu Kano Teaching Hospital, Kano, Nigeria. The hospital is a 500 bedded tertiary health care facility in the North-Western part of the country. It is a hospital with state of the art facilities for service, research and training and has 16 clinical departments with staff that provide selfless services to humankind. The approval to carry out the study was obtained from the research and Ethical Committee of Aminu Kano Teaching Hospital.
The subjects for the study were randomly selected from the population of staff of this hospital. The target population was a stratified subset of clinical staff with prime roles in patients' care. These are comprised of nurses, doctors and physiotherapists and as of July 2014 are, 513, 343 and 17, respectively. Furthermore, they were assigned numbers using an obtained nominal list from the hospital's administrative office.
Selection of participants
From the target population of 873 health workers, a proportionate calculation of the stratified sample was done and the respondents were selected by simple random sampling from the individual strata. A sample size of 267 at a 5% margin of error and 95% confidence interval was computed for the study, an additional 27 was added to have a total size of 294 after considering a possible 10% attrition during the study. The proportionate number of participants for the study (based on the ratio of 0.59:0.39:0.02) was 173 nurses, 115 doctors and six physiotherapists. The sampling technique used was simple random sampling. The hospital nominal list was used as a sampling frame. Each staff was assigned a number. To determine the number of participants to be interviewed in a particular week, the assigned numbers of each staff were written on the reverse side of pieces of papers. The papers were folded and thoroughly shaken in a bowl. The research assistant was asked to pick the papers randomly and open them. The corresponding names of those whose numbers were selected were recruited for interview that week. The bowl had to be shaken thoroughly before each selection. The name and assigned number of each participant interviewed were kept by the researchers. When a participant is selected, his or her name and assigned number had to be crossed checked from the list of the participants earlier interviewed to ensure that a participant was not recruited more than once.
Instrument for the study
A pilot tested self-administered questionnaire was designed for the study and was found to have both face and content validity [Appendix 1]. The self-administered questionnaire contained two parts, the first section elicited the respondent's sociodemographic characteristics such as age, sex occupation, department and field of specialisation. The second part of the questionnaire starts with a brief case vignette narration of someone with catatonic presentations. The next part has five lead questions with five yes/no response options for each question. The questions are meant to elicit the respondents' ability to identify catatonia, the type of illness, who to treat and where to treat [Appendix 5]. The alpha coefficient for the items on the respondents' ability to identify catatonia was α = 0.829 while the alpha coefficient for the items on the care of patients with catatonia was α = 0.863. The above correlational coefficients suggest that the items have relatively high internal consistency; therefore, the instrument has a high reliability for assessing the construct for the research.
To determine the face validity of the questionnaire, a sample of the questionnaires was distributed to doctors, nurses, physiotherapists and other hospital staff to ascertain their subjective opinion about the questions in the vignette that depicted catatonia. The respondents were able to identify a medical condition from the vignette and gave diverse views about the type of illness. This was not unexpected since the study was to elicit such responses. Therefore, the questionnaire seemed to have face validity. To determine content validity, the questionnaire was distributed to consultant psychiatrists who have severally managed patients with catatonia. They were able to identify the case in the vignette as catatonia.
The questionnaire was pilot tested among some doctors and nurses that were not part of the study sample and necessary revisions for clarity of questions were done after this.
Data were collected over a 6 weeks period with the designed questionnaire by personal contact of the selected respondents while in the hospital. The selected participants through simple random sampling were first notified through phone calls about intent to have them respond to a short survey at their convenience, but only when in the hospital. Moreover, the assumption was that a good number of them should be on duty about the same time. An appointment was scheduled with the willing participants while a repeat random sampling was done to replace the unwilling ones.
Data were analysed using statistical package for social sciences version 16.0 (IBM, Armonk, NY, USA). Quantitative variables were summarised using mean and standard deviation whereas categorical variables were summarised as frequencies and percentages.
| Results|| |
Sociodemographic characteristics of the respondents
[Table 1] shows the sociodemographic characteristics of the health workers that were interviewed. A total of 252 (86%) out of an anticipated 294 questionnaire responses were collated from the health workers. The mean age of the respondents was 35.9 years ± 7.61. Eighty (32%) were <5 years in the profession, 71 (28%) between 5 and 10 years, and 101 (40%) had worked for over 10 years.
Respondents' ability to identify catatonia
Among the respondents, 215 (85%) identified the case in the vignette as a mental illness, 74 (29%) as a neurological disorder and 61 (24%) as a mental and a neurological disorder. Eighty-seven (35%) of the respondents labeled the case catatonia, 155 (62%) called it schizophrenia, but 46 (18%) of the respondents could not name what the case depicted [Table 2].
Respondents' opinion on the clinical management of catatonia
Two-hundred twelve (84%) of the respondents believed only a psychiatrist should treat the case in the vignette, 62 (25%) favoured neurologists and 52 (21%) by both psychiatrists and neurologists. One hundred sixty-eight (67%) opinioned treating catatonia in a patient only in the psychiatric ward and only 13 (5%) of the respondents thought such a patient could be cared for in the medical ward [Table 3].
|Table 3: Responses on the opinion of the respondents to the care of patients with catatonia|
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The cross-tabulation analysis of the respondents' types of job and their ability to identify the case in the vignette as catatonia showed that a significant amount of physiotherapists than either the doctors or the nurses identified catatonia as both a mental and a neurological disorder (P < 0.05) [Appendix 2].
Treating patients with catatonia in the medical ward was much agreed to by only 12 (8%) of nurses, 1 (17%) of physiotherapist and none (0%) of the doctors [Appendix 3]. Irrespective of the respondents length of time in their fields of practice, 80% or more of them much felt that catatonia was a mental illness (P < 0.05). Moreover, more than 90% of same respondents definitely rejected catatonia as a form of epilepsy (P < 0.05) [Appendix 4].
In both M and N (both mental and neurological disorders), the care of patients with catatonia as that of psychiatrists was much opinioned by about 80% or more of the respondents despite their years in service (P < 0.05) [Appendix 5]. In addition, about 60% or more of them, irrespective of their years of work experience, were noticeably of the opinion that such patients be cared for in the psychiatric ward (P < 0.05). Most of the respondents despite their years of professional experience would not want a pregnant woman with catatonia cared for in the obstetrics ward (P < 0.05) [Appendix 5].
| Discussion|| |
This cross-sectional survey had a high response rate of 86% health workers most of whom were in adulthood, which is a time of an individuals' optimal intellectual, emotional and social functioning. In addition, more than two of every three of them had at least 5 years professional working experience in the hospital.
Despite a significant number of physiotherapists than either doctors or nurses' views on catatonia as both a mental and a neurological disorder, most of the health workers identified catatonia as a type of mental illness that many of them called schizophrenia disorder. This finding agrees with Ahuja's review claims that clinicians and other health professionals tend to see catatonia as a purely psychiatric disorder. This suggests that catatonia may not easily come into consideration when these health professionals treat patients with suspected medical or neurological illnesses, resulting in an underdiagnosis of catatonia when present among their patients. A large proportion of the health workers despite their years of professional experience thought catatonia was a disorder for only psychiatrists and be treated in the psychiatric ward. The health worker views show that catatonia is much viewed as an illness of schizophrenia disorder that is mainly an area of care by psychiatrists. However, only minorities (10%) of psychiatric patients with catatonia have schizophrenia, most of these have comorbid affective disorders.,, Catatonia also can be found in other medical conditions without psychiatric complications, one of which is epilepsy that a significant proportion of the health workers identified as not the same as catatonia. However, their low visibility in picking catatonia can make it a difficult task for them to identify persons with epileptic fits that are complicated by catatonia, a life-threatening condition of urgency in the afflicted.
| Conclusions|| |
The outcome of the study shows that majority of health professionals with prime role in patients' care had difficulty detecting catatonia. Most of them viewed catatonia as a purely mental illness that should be treated by a psychiatrist. The view of the majority of the participants was that patients with catatonia should be managed in psychiatric wards.
This study is limited by the study sample coming from a population of hospital staff in just one hospital making the result difficult to generalise. A larger study that involves more hospitals from the different geopolitical parts of the country should give a better generalisable research outcome.
Medical education programs should include issues such as catatonia that if not refreshed from time to time in the minds of health professionals cannot easily be remembered in their day to day practice. This can cause unnecessary fatalities, especially in patients who present with seemingly physical medical conditions that have an undetected catatonic complication by the managing team.
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Conflicts of interest
There are no conflicts of interest.
[Additional file 1]
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[Table 1], [Table 2], [Table 3]