Catatonia has a wide range of prevalence in different populations, from less than 10% to just above 60%.1–3 This may be influenced by factors that include the assessment tools used to screen for catatonia and the inter-rater reliability (IRR) among clinicians undertaking the assessment. In this descriptive study, we used the Bush Francis Catatonia Screening Instrument (BFCSI), Bush Francis Catatonia Rating Scale (BFCRS) and Diagnostic and Statistical Manual-5 (DSM-5) as assessment tools for catatonia.4 5 We analyzed data to determine the IRR among a group of five mental health professionals trained to apply these tools in an inpatient acute mental health setting. Data were collected from September 2020 to February 2021 as part of a larger 12-month study on catatonia in Dora Nginza Hospital, a general regional hospital in Nelson Mandela Bay, South Africa.
Assessment of catatonia
Tools or diagnostic systems such as the DSM-5 or International Classification of Diseases 10 (ICD-10), help to guide the clinical examination when assessing catatonia.3 4 Validity and IRR of assessment tools are important considerations that may influence the pick-up rate of catatonia, which makes it important to choose a valid assessment tool with acceptable IRR.5 6 The BFCSI meets these criteria as an acceptable screening tool because it has shown good IRR and has been successfully used at the study site to screen new admissions for catatonia.5 7 A number of studies have also indicated that the BFCSI is a reliable and valid screening tool for catatonia.3 5 7–10
The importance of diagnosing catatonia across all levels of mental healthcare—Lack of recognition of catatonia in the clinical setting has been a challenge for a long time but over the years there have been concerted efforts to increase recognition, diagnosis and treatment.2 9 Reasons for remaining challenges in recognition could be due to several factors including the assumption that catatonia is rare, the fluctuation and periodic nature of the presentation in some patients with waxing and waning of symptoms during an episode and the misinterpretation of catatonic symptoms as being “put on” by patients to gain attention.2 8–9
Rapid intervention to achieve resolution of catatonia is crucial to ensure that it has a good response and is resolved successfully.1–3 This may help prevent progression to chronic or more severe catatonia with potentially life-threatening complications. A longer duration of catatonia has been associated with a worse response to treatment. 1–3 Timely recognition and treatment may help to avoid the more serious complications of catatonia, some of which are potentially fatal. These include autonomic instability, bed sores, contractures, aspiration pneumonia, malnutrition, dehydration, renal failure, deep vein thrombosis and pulmonary embolus. 2 14–16
Due to the various causes of catatonia, it often presents in inpatient psychiatric settings but is also seen in accident and emergency settings, medical and neurological settings. When catatonia is missed, it delays diagnosis and has serious implications for response to treatment. This is because a good response to treatment has been found in patients with an acute onset.1–3 It is therefore crucial to sensitize staff in these settings to be alert to the possibility of catatonia and to know how to assess patients accurately, using reliable tools that are sensitive and relatively easy to apply for the average clinician working in such settings. This study researches the interrater reliability of three screening tools in an inpatient acute mental health setting and provides insight into applicability of these tools when used by nursing and medical staff who work in this setting.
Relevance of this research for mental health systems and policy— The current Mental Health Policy Framework and Strategic Plan of South Africa (2012 to 2020) is up for review and does not consider catatonia as an entity that requires focus when considering mental disorders across all levels of cate.17 The relevance of catatonia in the next mental health policy framework and also for future planning of mental health systems, is that taking it into consideration can provide an opportunity to ensure that it is an available of resource, since it is an effective treatment for catatonia. Thus, ensuring that availability of ECT is written into such a policy would have a bearing on access to this intervention for patients presenting with catatonia in future.
Comparing the BFCSI and DSM-5 in the assessment of catatonia—The BFCSI was developed by Bush et al. as a 14-item screening tool for catatonia. To assess the severity of catatonia, its use is complemented by completion of the full 23-item BFCRS if two or more signs of catatonia are present.5 7 The BFCRS has also been recommended by Sienaert et al. for routine use because of its good reliability, validity, and relative ease of application.9
In a study by Sarkar et al. on assessment of catatonia and IRR using four different instruments, more cases with catatonia were identified when applying the full BFCRS scale compared to the DSM-5, and IRR was demonstrated to be good (α = 0.779).4 10–12 Similar to this study, the number of the assessors in our study were five, consisting of three professional nurses and two psychiatry residents.