The current prevalence and factors associated with tardive dyskinesia among Filipino schizophrenic patients

Tardive dyskinesia in Asia- current clinical practice and the role of neurologists in the care pathway

Tardive dyskinesia (TD) is a movement disorder that can arise as a side effect of treatment with dopamine receptor-blocking agents (DRBAs), including antipsychotic drugs (APDs) used to manage psychotic illnesses. Second-generation APDs (SGAs) are often preferred to first-generation drugs due to their lower propensity to cause TD, however many SGAs-treated patients still develop the condition. Although TD is a global health concern, evidence regarding the occurrence of TD and how it is managed in Asian countries is currently limited. This article reports the results of a systematic review of the published literature on TD focusing on its prevalence, types of patients, knowledge of the condition, causative factors, and usual treatment pathways in clinical practice in Asian countries. Epidemiological data suggest that the prevalence of TD is increasing globally due to an overall rise in APD use, contributing factors being polypharmacy with multiple APDs, the use of higher than necessary doses, and off-label use for non-psychotic indications. Although exact prevalence figures for TD in Asian countries are difficult to define, there is a similar pattern of rising APD use which will result in increasing numbers of TD patients in this region. These issues need to be addressed and strategies developed to minimize TD risk and manage this disabling condition which impacts patients' quality of life and daily functioning. To date, both research into TD has been predominantly psychiatry focused and the perspectives from neurologists regarding the clinical management of this challenging condition are scarce. However, neurologists have an essential role in managing the movement disorders manifestations that characterize TD. Optimum management of TD, therefore, should ideally involve collaboration between psychiatrists and neurologists in joint care pathways, wherever practical. Collaborative pathways are proposed in this article, and the challenges that will need to be addressed in Asian countries to improve the care of people with TD are highlighted, with a focus on the neurologist's viewpoint and the implications for the management of TD globally.

Drug-Induced Movement Disorders and Its Associated Factors Among Patients Attending Treatment at Public Hospitals in Eastern Ethiopia

BACKGROUND

Antipsychotic medications have both beneficial and undesired effects at a dose used for treatment purposes. Among undesired effects caused by antipsychotics, movement disorders are prevalent. However, there is no study done to determine the prevalence of movement disorders that occurred due to antipsychotics and their determinants in eastern Ethiopia.

OBJECTIVE

This study aimed to find out the prevalence of drug-induced movement disorders and its determinants among patients who had been on follow-up at public hospitals in eastern Ethiopia.

METHODS

A cross-sectional study was conducted from May to June 2018 at HFSUH and Jugal hospital. Extrapyramidal symptom rating scale (ESRS) was used to identify patients with drug-induced movement disorders in a sample of 411 outpatients. A systematic random sampling method was used to select the sample. Logistic regression was done to identify factors associated.

RESULTS

A drug-induced movement disorder was found in 44% of the participants: Of this, 27.3% had drug-induced pseudo-Parkinsonism, 21.2% had drug-induced akathisia, 9.5% had drug-induced tardive dyskinesia, and 3.4% had drug-induced tardive dystonia. Being female was associated with pseudo-Parkinsonism (AOR=3.6, 95% CI: 2.03, 6.35), akathisia (AOR=4.9, 95% CI: 2.73, 8.78), and tardive dyskinesia (AOR=2.51, 95% CI: 1.08, 5.86) and being male with tardive dystonia (AOR=4.6, 95% CI: 1.8, 18.5). Alcohol use was associated with tardive dyskinesia (AOR= 5.89, 95% CI: 2.20, 15.69).

CONCLUSION

Drug-induced movement disorder in this study was high and nearly half of patients on antipsychotic treatment were experiencing it. Age, sex, and doses of antipsychotics were factors associated with all of the types of drug-induced movement disorders.

Tardive syndromes

Dopamine receptor-blocking antipsychotics, first introduced into clinical practice in 1952, were hailed as a panacea in the treatment of a number of psychiatric disorders. However, within 5 years, this notion was to be shattered by the recognition of both acute and chronic drug-induced movement disorders which can accompany their administration. Tardive syndromes, denoting the delayed onset of movement disorders following administration of dopamine receptor-blocking (and also other) drugs, have diverse manifestations ranging from the classic oro-bucco-lingual dyskinesia, through dystonic craniocervical and trunk posturing, to abnormal breathing patterns. Although tardive syndromes have been an important part of movement disorder clinical practice for over 60 years, their pathophysiologic basis remains poorly understood and the optimal treatment approach remains unclear. This review summarises the current knowledge relating to these syndromes and provides clinicians with pragmatic, clinically focused guidance to their management.

Analysis of risk factors and outcomes in psychiatric inpatients with tardive dyskinesia: A nationwide case-control study

Objective

To analyze comorbidities and outcomes in patients with tardive dyskinesia (TD) during psychiatric inpatient management.

Methods

We conducted a case-control study using the Nationwide Inpatient Sample. It included 77,022 adult inpatient admissions for mood disorders and schizophrenia. Cases had a secondary diagnosis of TD, and controls without TD were matched for age. Multivariable logistic regression was used to generate odds ratio (OR).

Results

Majority of TD patients were older age adults (50–64 years; 40%), and were in nearly equal proportions of men and women. African Americans had two-fold higher odds of TD. TD patients had a higher likelihood for cardio-metabolic comorbidities-obesity (OR 1.61, 95% CI 1.481–1.756), hypertension (OR 1.78, 95% CI 1.635–1.930) and diabetes (OR 1.54, 95% CI 1.414–1.680) compared to controls. They also had 1.5-fold increased risk of comorbid drug abuse. Patients with schizophrenia and bipolar disorder (depressive) had four-fold higher odds of TD. TD patients had about six-fold higher odds of severe morbidity. They had a higher likelihood of extended hospitalization stay by 6.36 days (95% CI 6.174–6.550) and higher cost by $20,415 (95% CI 19537–21293) compared to controls.

Conclusion

Psychiatric inpatients with TD have greater severity of illness, and those with schizophrenia and bipolar disorders are at highest risk. Presence of TD portends poor hospital outcomes and need for higher acute inpatient care.

Study on risk factors of extrapyramidal symptoms induced by antipsychotics and its correlation with symptoms of schizophrenia

Background

Extrapyramidal symptoms (EPS) are one of the most common and neglected side effects during the treatment of schizophrenia. The risk factors of EPS in Chinese patients with schizophrenia and its relationship with psychiatric symptoms and mood symptoms of schizophrenia remain unknown.

Aims

The main objective of this study is to explore the risk factors of EPS caused by antipsychotics and the relationship between EPS and psychotic symptoms and mood symptoms of schizophrenia.

Method

This study included 679 patients with schizophrenia who have met the diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition. Patients were divided into the EPS group and the non-EPS group according to the scale rating criteria and whether the anticholinergics have been used. The differences between demographic data and characters of drug intake were compared between the two groups, and the risk factors of EPS were selected between those factors. Correlation analysis was performed on the severity of schizophrenia (Positive and Negative Symptoms Scale (PANSS), Calgary Depression Scale for Schizophrenia (CDSS) score) and EPS scale (Simpson-Angus Scale (SAS), Barnes Akathisia Rating Scale (BARS), Abnormal Involuntary Movement Scale (AIMS) score) in 679 patients. The differences between the PANSS subscale score and the CDSS score between the EPS group and the non-EPS group were compared.

Result

Compared with the non-EPS group, the EPS group patients are older, and they have a longer duration since first prescribed antipsychotics. The EPS group patients have higher frequency of atypical antipsychotics polytherapy and typical and atypical antipsychotics polytherapy or combined treatments with mood stabilisers. Logistic regression analysis shows that antipsychotics with high D2 receptor antagonistic effect and illness duration are the risk factors of EPS. The SAS score was significantly correlated with PANSS negative score, PANSS general psychopathological score and PANSS total score. The BARS scale score was significantly correlated with PANSS positive score, PANSS general psychopathological score, PANSS total score and CDSS total score. The AIMS scale score was significantly correlated with PANSS negative score. Compared with the non-EPS group, the EPS group patients have significantly higher PANSS negative score, PANSS general psychopathological score, PANSS total score and CDSS total score.

Conclusion

Antipsychotic drugs with high D2 receptor antagonism and disease duration are risk factors of EPS in Chinese patients with schizophrenia. The severity of various types of EPS is significantly correlated with the psychiatric and mood symptoms of schizophrenia, and psychiatric symptoms and mood symptoms were significantly more severe in the EPS group. The occurrence of EPS is associated with poor treatment outcome of schizophrenia.

Prevalence and management practice of first generation antipsychotics induced side effects among schizophrenic patients at Amanuel Mental Specialized Hospital, central Ethiopia: cross-sectional study

BACKGROUND

First-generation antipsychotics (FGAs) are associated with a range of adverse events which can significantly reduce patients' quality of life and contribute to non-adherence. The aim of this study was to assess the prevalence and management practice of first generation antipsychotics induced side effects among schizophrenic patients.

METHODS

The study was conducted at Amanuel Mental Specialized Hospital from March to June, 2017. Data from patients were collected using a pretested structured questionnaire. Demographics and side effects of antipsychotics were collected by face to face interview. Clinical characteristics, medications and previous history of adverse drug events were extracted from medical records using data abstraction format. The data were analyzed using statistical software for social sciences (SPSS) version 20. Descriptive statistics and chi-square tests were done. Statistical significance was considered at p < 0.05.

RESULTS

Out of 356 participants, 300 of them had complete data and were included in the study. The mean age of participants was 33.71 ± 10.2 years. The majority, 195(65.0%), of participants were males. Most of the participants, 293(97.7%), developed FGA medication induced side effects. One hundred sixty three (54.3%) participants were treated with Trihexyphenidyl for FGAs induced side effects. Dose reduction of antipsychotics was done for 51(17.0%) participants. Most of the participants' side effects were not managed according to American Psychiatric Association guideline; 178 (82.4%). The most common types of FGAs induced side effects were cardiovascular side effects 169(56.3%); sedation and CNS side effects 149(49.6%); and extrapyramidal side effects 114(38.0%). There is a significant association between occurrence of side effects of FGAs and duration of illness (P = 0.04).

CONCLUSIONS

The prevalence of first generation antipsychotics induced side effects was high. However, management practice of the side effects was minimal.

Development and clinimetric assessment of a nurse-administered screening tool for movement disorders in psychosis

BACKGROUND

Movement disorders associated with exposure to antipsychotic drugs are common and stigmatising but underdiagnosed.

AIMS

To develop and evaluate a new clinical procedure, the ScanMove instrument, for the screening of antipsychotic-associated movement disorders for use by mental health nurses.

METHOD

Item selection and content validity assessment for the ScanMove instrument were conducted by a panel of neurologists, psychiatrists and a mental health nurse, who operationalised a 31-item screening procedure. Interrater reliability was measured on ratings for 30 patients with psychosis from ten mental health nurses evaluating video recordings of the procedure. Criterion and concurrent validity were tested comparing the ScanMove instrument-based rating of 13 mental health nurses for 635 community patients from mental health services with diagnostic judgement of a movement disorder neurologist based on the ScanMove instrument and a reference procedure comprising a selection of commonly used rating scales.

RESULTS

Interreliability analysis showed no systematic difference between raters in their prediction of any antipsychotic-associated movement disorders category. On criterion validity testing, the ScanMove instrument showed good sensitivity for parkinsonism (90%) and hyperkinesia (89%), but not for akathisia (38%), whereas specificity was low for parkinsonism and hyperkinesia, and moderate for akathisia.

CONCLUSIONS

The ScanMove instrument demonstrated good feasibility and interrater reliability, and acceptable sensitivity as a mental health nurse-administered screening tool for parkinsonism and hyperkinesia.

DECLARATION OF INTEREST

None.

New findings in pharmacogenetics of schizophrenia

PURPOSE OF REVIEW

This review highlights recent advances in the investigation of genetic factors for antipsychotic response and side effects.

RECENT FINDINGS

Antipsychotics prescribed to treat psychotic symptoms are variable in efficacy and propensity for causing side effects. The major side effects include tardive dyskinesia, antipsychotic-induced weight gain (AIWG), and clozapine-induced agranulocytosis (CIA). Several promising associations of polymorphisms in genes including HSPG2, CNR1, and DPP6 with tardive dyskinesia have been reported. In particular, a functional genetic polymorphism in SLC18A2, which is a target of recently approved tardive dyskinesia medication valbenazine, was associated with tardive dyskinesia. Similarly, several consistent findings primarily from genes modulating energy homeostasis have also been reported (e.g. MC4R, HTR2C). CIA has been consistently associated with polymorphisms in the HLA genes (HLA-DQB1 and HLA-B). The association findings between glutamate system genes and antipsychotic response require additional replications.

SUMMARY

The findings to date are promising and provide us a better understanding of the development of side effects and response to antipsychotics. However, more comprehensive investigations in large, well characterized samples will bring us closer to clinically actionable findings.

Antipsychotic-induced Tardive dyskinesia: from biological basis to clinical management

INTRODUCTION

Tardive dyskinesia (TD) is a chronic and disabling movement disorder with a complex pathophysiological basis. A significant percentage of patients does not receive correct diagnosis, resulting in delayed or inaccurate treatment and poor outcome. Therefore, there is a critical need for prompt recognition, implementation of efficacious treatment regimens and long-term follow up of patients with TD. Areas covered: The current paper provides an overview of emerging data concerning proposed pathophysiology theories, epidemiology, risk factors, and therapeutic strategies for TD. Expert commentary: Despite considerable research efforts, TD remains a challenge in the treatment of psychosis as the available strategies remain sub-optimal. The best scenario will always be the prophylaxis or prevention of TD, which entails limiting the use of antipsychotics.

The prevalence of diabetes mellitus and abnormal glucose metabolism in the inpatient psychiatric setting: A systematic review and meta-analysis

OBJECTIVE

To systematically determine the prevalence of diabetes mellitus (DM), impaired fasting glucose (IFG), and impaired glucose tolerance (IGT) in psychiatric inpatients and explore the impact of patient and study variables on prevalence estimates.

METHOD

We searched EMBASE, PsychINFO, Medline and CENTRAL from database inception until 1st December 2015. We included studies of any design reporting prevalence of abnormal glucose metabolism in any adult psychiatric inpatients. We conducted a random effects meta-analysis to generate pooled prevalence estimates. Chi-square tests compared differences within categorical variables (inpatient setting, continent of study and patient diagnostic category) and Spearman's correlation analyses assessed the impact of linear variables (age, year of data collection and study quality). Study quality was assessed using an adapted Newcastle-Ottawa Scale.

RESULTS

36 study reports representing 42 unique cohorts were included. Across all studies prevalence of unspecified type DM was 10% (95%CI: 9-12), of T1DM was 1% (0-1), of T2DM was 9% (6-13), of IFG 18% (8-28), and of IGT was 22% (16-28). These estimates were not affected by study quality.

CONCLUSIONS

All estimates are higher compared to the general population. Mental health professionals should be aware of this elevated prevalence to improve screening and management of abnormal glucose metabolism.

Pharmacogenetics of tardive dyskinesia: an updated review of the literature

Tardive dyskinesia (TD) is a serious and potentially irreversible side effect of long-term exposure to antipsychotic medication characterized by involuntary trunk, limb and orofacial muscle movements. Various mechanisms have been proposed for the etiopathophysiology of antipsychotic-induced TD in schizophrenia patients with genetic factors playing a prominent role. Earlier association studies have focused on polymorphisms in CYP2D6, dopamine-, serotonin-, GABA- and glutamate genes. This review highlights recent advances in the genetic investigation of TD. Recent promising findings were obtained with the HSPG2, DPP6, MTNR1A, SLC18A2, PIP5K2A and CNR1 genes. More research, including collection of well-characterized samples, enhancement of genome-wide strategies, gene–gene interaction and epigenetic analyses, is needed before genetic tests with clinical utility can be made available for TD.

A Case Report on Dyskinesia Following Rivastigmine Patch 13.3 mg/24 hours for Alzheimer's Disease: Perspective in the Movement Disorders Spectrum Following Use of Cholinesterase Inhibitors

Current reports on movement disorder adverse effects of acetylcholinesterase inhibitors only include extrapyramidal symptoms and myoclonus.Here is a case of an 81-year-old female Filipino with dementia who presented with first-onset generalized choreiform movements.The etiology of the clinical finding of dyskinesia was investigated through laboratories, neuroimaging, and electroencephalogram, all of which yielded negative results. Review of her medications included the rivastigmine (Exelon) patch, which had just been increased to 13.3 mg/24-hour-dose 3 months prior. With all other possible causes excluded, a trial discontinuation of rivastigmine, showed decreased frequency of the dyskinesia 48 hours after, with complete resolution after 6 days, and no recurrence since then.This case thus presents a probable association or causality between the choreiform movement and rivastigmine at 13.3 mg/24-hour-dose patch because of clear temporal proximity, lack of alternative explanations, and a reversal of the dyskinesia upon medicament discontinuation.

Antipsychotics-induced tardive syndrome: a retrospective epidemiological study

OBJECTIVES

Only little information of the epidemiology of tardive syndrome in patients using antipsychotics is available. Herein, we aimed to investigate the prevalence and risk factors of antipsychotics-induced tardive syndrome.

METHODS

This study was conducted by means of a retrospective survey. Subjects receiving antipsychotics for more than 6 months, but no other agents that may cause involuntary movements, were consecutively recruited. Tardive syndrome was evaluated in every included subject. Possible confounding medical conditions were carefully ruled out.

RESULTS

Of the 123 included subjects, 35 (28.5%) were found to have at least 1 episode of tardive syndrome. The prevalence of subtypes of tardive syndrome were as follows: tardive dyskinesia, 21.1%; tardive dystonia, 12.5%; tardive tremor, 2.4%; and tardive akathisia, 2.4%. Concurrent physical illness and a history of extrapyramidal symptoms were significant risk factors for tardive syndrome.

CONCLUSIONS

This study showed that antipsychotics may induce various types of tardive syndrome, of which tardive dyskinesia is the most predominant one. Physicians should be aware of this common and distressing adverse effect when using antipsychotics.

Prevalence and risk factors associated with tardive dyskinesia among Indian patients with schizophrenia

BACKGROUND

Tardive dyskinesia (TD) is one of the most distressing side effects of antipsychotic treatment. As prevalence studies of TD in Asian population are scarce, a cross-sectional study was performed to assess the frequency of TD in Indian patients with schizophrenia and risk factors of TD.

METHOD

Cross-sectional study of 160 Indian patients fulfilling the DSM-IV TR criteria for schizophrenia and who received antipsychotics for at least one year, were examined with two validated scales for TD. Logistic regression analyses were used to examine the relationship between TD and clinical risk factors.

RESULTS

The frequency of probable TD in the total sample was 26.4%. The logistic regression yielded significant odds ratios between TD and age, intermittent treatment, and total cumulative antipsychotic dose. The difference of TD between SGA and FGA disappeared after adjusting for important co-variables in regression analysis.

CONCLUSION

Indian patients with schizophrenia and long-term antipsychotic treatment have a high risk of TD, and TD is associated with older age, intermittent antipsychotic treatment, and a high total cumulative antipsychotic dose. Our study findings suggest that there is no significant difference between SGAs with regards to the risk of causing TD as compared to FGAs.

Movement disorders in patients with diabetes mellitus

Movement disorders are not infrequent in patients with diabetes mellitus. These may occur on the basis of both central and peripheral nervous system dysfunction and can be secondary to severe hyperglycemia, complications of diabetes or its treatment and less often to diseases in which both diabetes and a movement disorder are primary manifestations of the same underlying disease. We present a typical case of a severe movement disorder complicating diabetes as a springboard to review the spectrum of disorders associated with this condition.

Glial cell line-derived neurotrophic factor receptor alpha 2 (GFRA2) gene is associated with tardive dyskinesia

INTRODUCTION

Tardive dyskinesia (TD) has a pharmacogenetic component in which the interaction of antipsychotic exposure with individual genetic variation mediates risk. The glial cell line-derived neurotrophic factor (GDNF) signalling pathway has been associated with neuroprotective effects in central dopaminergic neurons and spinal motor neurons. Clinical trials have also investigated whether GDNF may ameliorate Parkinson's disease symptoms.

METHODS

We tested whether variants in the GDNF receptor alpha 2 (GFRA2) gene could play a role in TD susceptibility evaluating 16 variants in 172 Caucasian schizophrenia subjects.

RESULTS

We observed one significant allelic association (rs4739285, permuted p = 0.042) and two genotypic associations: rs4739285 under additive inheritance model and rs4739217 under dominant inheritance model (permuted p = 0.044). Moreover, carriers of the major alleles for both rs6587002 and rs4739217 presented significantly higher risk for TD (OR = 2.04, permuted p = 0.014), while subjects with the minor allele for rs4739217 and the major allele for rs6988470 were less likely to have TD (OR = 0.21, permuted p = 0.0007).

DISCUSSION

Haplotype results indicate that the minor allele of the rs4739217 is a risk factor for TD (permuted allelic p = 0.074). Age was also a risk factor for TD in our sample (p = 0.0001). Taken together, our findings suggest that GFRA2 genetic variants and age may play a role in TD susceptibility, but further work is required to confirm these findings.