title: Catatonia in resource-limited settings: a case series and treatment protocol.
abstract: OBJECTIVE
  The catatonic syndrome ("catatonia") is characterized by motor and motivation dysregulation and is associated with a number of neuropsychiatric and medical disorders. It is recognizable in a variety of clinical settings. We present observations from the treatment of four individuals with catatonia in Haiti and Rwanda and introduce a treatment protocol for use in resource-limited settings.
  
  
  METHODS
  Four patients from rural Haiti and Rwanda with clinical signs of catatonia and a positive screen using the Bush-Francis Catatonia Rating Scale were treated collaboratively by general physicians and mental health clinicians with either lorazepam or diazepam. Success in treatment was clinically assessed by complete remittance of catatonia symptoms.
  
  
  RESULTS
  The four patients in this report exhibited a range of characteristic and recognizable signs of catatonia, including immobility/stupor, stereotypic movements, echophenomena, posturing, odd mannerisms, mutism and refusal to eat or drink. All four cases presented initially to rural outpatient general health services in resource-limited settings. In some cases, diagnostic uncertainty initially led to treatment with typical antipsychotics. In each case, proper identification and treatment of catatonia with benzodiazepines led to significant clinical improvement.
  
  
  CONCLUSIONS
  Catatonia can be effectively and inexpensively treated in resource-limited settings. Identification and management of catatonia are critical for the health and safety of patients with this syndrome. Familiarity with the clinical features of catatonia is essential for health professionals working in any setting. To facilitate early recognition of this treatable disorder, catatonia should feature more prominently in global mental health discourse.
authors.affiliation: Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA, USA 02115; Partners In Health, 888 Commonwealth Avenue, 3rd Floor, Boston, MA USA 02215; Division of Medical Psychiatry, Brigham and Women's Hospital, 75 Francis Street, Boston, MA USA 02115. Electronic address: Stephanie_Smith@hms.harvard.edu.
authors.forename: Stephanie L
authors.initials: SL
authors.lastname: Smith
authors.affiliation: Partners In Health, 888 Commonwealth Avenue, 3rd Floor, Boston, MA USA 02215; Department of Epidemiology, Harvard School of Public Health, 677 Huntington Avenue, Boston, MA, USA 02115.
authors.forename: David J
authors.initials: DJ
authors.lastname: Grelotti
authors.affiliation: Department of Mental Health and Psychosocial Services, Zanmi Lasante, Haiti.
authors.forename: Reginald
authors.initials: R
authors.lastname: Fils-Aime
authors.affiliation: Butaro Hospital, Ministry of Health, Burera District, Rwanda.
authors.forename: Eugenie
authors.initials: E
authors.lastname: Uwimana
authors.affiliation: Butaro Hospital, Ministry of Health, Burera District, Rwanda.
authors.forename: Jean-Sauveur
authors.initials: JS
authors.lastname: Ndikubwimana
authors.affiliation: Department of Mental Health and Psychosocial Services, Zanmi Lasante, Haiti.
authors.forename: Tatiana
authors.initials: T
authors.lastname: Therosme
authors.affiliation: Department of Mental Health and Psychosocial Services, Zanmi Lasante, Haiti.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Severe
authors.affiliation: Butaro Hospital, Ministry of Health, Burera District, Rwanda.
authors.forename: Dominique
authors.initials: D
authors.lastname: Dushimiyimana
authors.affiliation: Butaro Hospital, Ministry of Health, Burera District, Rwanda.
authors.forename: Clemence
authors.initials: C
authors.lastname: Uwamariya
authors.affiliation: Butaro Hospital, Ministry of Health, Burera District, Rwanda.
authors.forename: Robert
authors.initials: R
authors.lastname: Bienvenu
authors.affiliation: Department of Mental Health and Psychosocial Services, Zanmi Lasante, Haiti.
authors.forename: Yoldie
authors.initials: Y
authors.lastname: Alcindor
authors.affiliation: Department of Mental Health and Psychosocial Services, Zanmi Lasante, Haiti.
authors.forename: Eddy
authors.initials: E
authors.lastname: Eustache
authors.affiliation: Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA, USA 02115; Partners In Health, 888 Commonwealth Avenue, 3rd Floor, Boston, MA USA 02215.
authors.forename: Giuseppe J
authors.initials: GJ
authors.lastname: Raviola
authors.affiliation: Division of Psychiatry and Medicine, Pierce Division of Global Psychiatry, Massachusetts General Hospital, 55 Fruit Street, Boston, MA USA 02114.
authors.forename: Gregory L
authors.initials: GL
authors.lastname: Fricchione
mesh_terms: D000293:Adolescent; D000328:Adult; D002389:Catatonia / Q000628:therapy*; D003975:Diazepam / Q000008:administration & dosage / Q000494:pharmacology; D005260:Female; D006205:Haiti; D006801:Humans; D008140:Lorazepam / Q000008:administration & dosage / Q000494:pharmacology; D008297:Male; D009125:Muscle Relaxants, Central / Q000008:administration & dosage / Q000494:pharmacology*; D012432:Rwanda
chemical_list: D009125:Muscle Relaxants, Central; D008140:Lorazepam; D003975:Diazepam
keywords: Africa; Caribbean region; Catatonia; Neuropsychiatry; Psychosomatic medicine