Prevalence of and risk factors for tardive dyskinesia in a Xhosa population in the Eastern Cape of South Africa

Psychotropic Medications-Induced Tardive Dyskinesia and Associated Factors Among Patients with Mental Illness in Ethiopia

BACKGROUND

Tardive dyskinesia (TD) remains a significant burden especially among patients taking psychotropic medications, and it is associated with adverse effects that can lead to subjective suffering, stigma, poor compliance to medication, and poor quality of life. However, it is unrecognized and overlooked in clinical settings. So, this study aimed to assess the magnitude of tardive dyskinesia and associated factors among mentally ill patients attending follow-up treatment at Jimma University Medical Center Psychiatry clinic, Jimma, Southwest Ethiopia, 2019.

METHODS

Institutional-based cross-sectional study design was conducted in 417 samples. Participants were selected by systematic random sampling techniques. Data were collected by a semi-structured interviewer-administered questionnaire, and the document was reviewed to obtain the patient's profile. Tardive dyskinesia was assessed by using the Extrapyramidal Symptom Rating Scale after informed consent was obtained from respondents. Data entry was done by EpiData version 3.1, and analysis was done by using SPSS 22.0 statistical software. Binary logistic regression and multivariate logistic regression were used to see the association and to identify independent factors at a p-value of <0.05.

RESULTS

Prevalence of drug-induced tardive dyskinesia was 15.4% (CI 95%: 12.0, 19.3). Female, age range between 30 and 44 years, having a diagnosis of major depressive disorder with the psychotic feature, taking chlorpromazine equivalent dose ˃600mg, and taking anticholinergic medications were variables positively associated with tardive dyskinesia, whereas cigarette smoking was negatively associated with tardive dyskinesia.

CONCLUSION

The prevalence of drug-induced tardive dyskinesia in this study was high. Prescribing medications less than 600mg equivalent dose of chlorpromazine, giving attention for female patients, patients having a diagnosis of major depressive disorder, and reducing giving anticholinergic medications will be important measures for clinicians to reduce the occurrence of tardive dyskinesia.

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.

Does the degree of smoking effect the severity of tardive dyskinesia? A longitudinal clinical trial

Background

Tardive dyskinesia (TD) is a movement disorder observed after chronic neuroleptic treatment. Smoking is presumed to increase the prevalence of TD. The question of a cause-effect-relationship between smoking and TD, however, remains to be answered. Purpose of this study was to examine the correlation between the degree of smoking and the severity of TD with respect to differences caused by medication.

Method

We examined 60 patients suffering from schizophrenia and TD. We compared a clozapine-treated group with a group treated with typical neuroleptics. Movement disorders were assessed using the Abnormal-Involuntary-Movement-Scale and the technical device digital image processing, providing rater independent information on perioral movements.

Results

We found a strong correlation (.80 < r < .90, always p < .0001) between the degree of smoking and severity of TD. Repeated measurements revealed a positive correlation between changes in cigarette consumption and changes of the severity of TD (p < .0001). Analyses of covariance indicated a significant group-effect with a lower severity of TD in the clozapine-group compared to the typical-neuroleptics-group (p = .010). Interaction-analyses indicated a higher impact of smoking on the severity of TD in the typical-neuroleptics-group compared to the clozapine-group (p = .033).

Conclusion

Concerning a possible cause-effect-relationship between smoking and TD, smoking is more of a general health hazard than neuroleptic exposure in terms of TD.

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.

Utilizing the concept of geste antagoniste for conservative management of oro-mandibular tardive dyskinesia: a case report and mini-review

OBJECTIVE

This case report highlights the implication of the concept of "geste antagoniste" in conservatively managing oromotor dysfunction and its complications.

CLINICAL PRESENTATION

A 66-year-old female with a 1-year history of tardive dyskinesia (TD) was referred to the Craniofacial Pain Department (CPC) at Tufts University School of Dental Medicine for management of sore labial/lingual mucosa secondary to excessive daytime involuntary activity of the tongue, lips, and mandible. A detailed head/neck examination revealed excessive involuntary movements of the tongue, lips, and mandible with generalized tenderness of her masticatory muscles. No TMJ or bone pathology was evident in a panoramic radiograph.

INTERVENTION

A lower daytime appliance with bilateral posterior contacts was fabricated to protect her oral mucosa. On reevaluation, excessive movement of the jaw/tongue was significantly reduced with the presence of the appliance in her mouth. Face/neck muscle tenderness was also greatly reduced.

CONCLUSION

The use of oral appliance therapy in TD patients plays an important role in protecting the teeth/oral mucosa. The subsequent inhibition of excessive motor activity is proposed and should be further investigated.

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.

Tardive dyskinesia is associated with greater cognitive impairment in schizophrenia

OBJECTIVE

Schizophrenia is a psychiatric disorder diagnosed by the presence of a number of symptoms with cognitive impairment as a core feature. Long-term antipsychotic treatment is often associated with the emergence of tardive dyskinesia (TD) and the presence of TD is linked to cognitive impairment. This study examined the relationship between TD and cognitive deficits in Chinese patients with schizophrenia.

METHODS

We recruited 206 chronic patients with TD (n=102) and without TD (n=104) meeting DSM-IV criteria for schizophrenia and 104 control subjects who were matched on age, gender, and education. All the patients completed the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), Positive and Negative Symptom Scale (PANSS), and the Abnormal Involuntary Movement Scale (AIMS).

RESULTS

The PANSS total score (p=0.01), N subscore (p=0.006), and AIMS total score (p<0.001) were significantly higher in patients with TD compared to patients without TD. Patients with TD scored lower for visuospatial/constructional, attention, and total index scores (all p<0.001) on the RBANS. AIMS orofacial scores were identified as an independent contributor to RBANS total scores and attention index (p<0.05), whereas AIMS limb and truncal scores were an independent determinant to the visuospatial/constructional index of RBANS (p<0.05).

CONCLUSION

TD was associated with greater cognitive impairment in patients with schizophrenia compared to those without TD. The orofacial and limb-trunk TD specifically appeared to be a risk factor or contributor to the different aspects of cognitive deficits in schizophrenia. The association between schizophrenia and TD may be explained in part by oxidative stress.

Epidemiology of tardive dyskinesia before and during the era of modern antipsychotic drugs

Late or tardive dyskinesias/dystonias (TD), contrary to expectation, have not disappeared with the use of expensive, modern antipsychotic drugs (APDs). Risk appears to be substantially lower than with older neuroleptics, and there is sparing of most acute movement disorders traditionally associated with APD treatment. However, risks of TD with modern APDs have been reduced much less than expected, by perhaps two- to threefold or even less, with substantial risks in the elderly. Major challenges in assessing prevalence or, preferably, incidence of TD arise from prolonged and erratic past exposure to various APDs, relatively recent use of modern APDs, and the occurrence of spontaneous movement disorders (about 5% and more in the elderly). TD risks associated with modern APDs may be similar to some older neuroleptics, especially those of low-moderate potency. Risperidone (and its active metabolite paliperidone), at high doses, may carry unusually high TD risk, whereas TD risk is low with clozapine, and perhaps quetiapine and aripiprazole. Optimistic expectations for the efficacy and neurological safety of modern APDs have encouraged their wide use in many conditions, sometimes off-label or in combinations, with little research support, increasing the chance of a higher prevalence of TD, especially at older ages. Measures to limit TD risk include: (1) critical, objective indications for APD use; (2) long-term use only for compelling or research-supported indications, primarily chronic psychotic illness that worsens when APD is slowly discontinued; (3) avoiding off-label indications; (4) using alternative treatments when APD treatment is elective, or early dyskinesia is identified; (5) using low but effective doses of single APDs, especially in the elderly; and (6) regular and specific examination for early TD.

Gender differences in the prevalence, risk and clinical correlates of tardive dyskinesia in Chinese schizophrenia

OBJECTIVE

Despite extensive use of antipsychotic drug treatment, few studies address the prevalence of tardive dyskinesia (TD) in homogeneous ethnic groups such as the Chinese. This study examined gender-specific relationships between TD and symptom levels in schizophrenia among Han Chinese, which have previously received little systematic study.

MATERIALS AND METHODS

Five hundred and twenty-two inpatients with schizophrenia receiving long-term treatment with antipsychotics were evaluated with the AIMS. The patient's psychopathology was assessed with the Positive and Negative Syndrome Scale (PANSS). Demographic and clinical data were collected from a detailed questionnaire and medical records.

RESULTS

The overall TD prevalence was 33.7% with rates of 39.2% (138/352) in males and 22.4% (38/170) in females (chi (2) = 14.6, df = 1, p < 0.0001; adjust odds ratio 2.06; CI, 1.32-3.16). The AIMS score in patients with TD was lower in females than males (5.3 +/- 3.9 vs 6.7 +/- 3.7, t = 2.52, p < 0.01) after adjustment for the significant covariates. TD was associated with the negative symptoms on the PANSS in both genders, and with age, PANSS total and positive symptoms in men, not women.

CONCLUSION

Our present findings suggest that there are gender differences in the prevalence, risk, and clinical correlates of TD in schizophrenia. Although this study is limited by cross-sectional designs, the magnitude of these gender-specific differences is substantial and deservers further prospective study.

Tardive dyskinesia and new antipsychotics

PURPOSE OF REVIEW

To provide an update on tardive dyskinesia rates in patients treated with first-generation or second-generation antipsychotics in studies published since the last systematic review in 2004.

RECENT FINDINGS

Across 12 trials (n = 28 051, age 39.7 years, 59.7% male, 70.9% white, followed for 463 925 person-years), the annualized tardive dyskinesia incidence was 3.9% for second-generation antipsychotics and 5.5% for first-generation antipsychotics. Stratified by age, annual tardive dyskinesia incidence rates were 0.35% with second-generation antipsychotics in children, 2.98% with second-generation antipsychotics versus 7.7% with first-generation antipsychotics (P < 0.0001) in adults, and 5.2% with second-generation antipsychotics versus 5.2% with first-generation antipsychotics (P = 0.865) in the elderly (based almost exclusively on one retrospective cohort study). In four adult studies (n = 2088, age 41.2 years, 71.2% male, 62.0% white), tardive dyskinesia prevalence rates were 13.1% for second-generation antipsychotics, 15.6% for antipsychotic-free patients, and 32.4% for first-generation antipsychotics (P < 0.0001).

SUMMARY

Current evidence supports a lower tardive dyskinesia risk for second-generation antipsychotics than for first-generation antipsychotics. Tardive dyskinesia incidence was higher with second-generation antipsychotics than previously reported, possibly due to recent studies with relatively short mean durations and use of nonstandard tardive dyskinesia definitions.

The course of tardive dystonia in Afro Caribbean patients, a population-based study: the Curacao extrapyramidal syndromes study: VII

Tardive dystonia (TDt) is a severe side effect of long-term use of antipsychotics. Previous publications suggested that TDt persist but the results are distorted by referral bias. In a population-based nine-year follow-up study (one baseline, six follow-ups) of chronic psychiatric patients (N=194) on a Caribbean island, the course of prevalent and incident TDt was measured with the Fahn-Marsden rating scale. Of the 26 patients (mean age 53.3 yrs) with TDt at baseline, 64% recovered, 20% persisted, and in 16% the course was intermittent. The severity of baseline TDt was significantly higher in persistent cases versus those who recovered (t=3.01, P<0.008). Of the 27 incident cases (cumulative 9-year incidence: 16.1%; mean age 57.6 yrs), 80% recovered, 8% persisted, and in 12% the course was intermittent. Predominantly affected were hands, eyes (blepharospasm), neck and mouth. The natural course of TDt is better than previously suggested but severe cases tend to persist.

Factors associated with antipsychotic dosing in psychiatric inpatients: a prospective study

The persistent use of doses in excess of recommended levels is associated with increased risks of adverse reactions without evidence of additional benefits. Such treatment modality was evaluated in hospitalized psychiatric patients. During a 6-year recruitment period, a consecutive series of psychiatric inpatients receiving antipsychotic therapy were included. At admission, sociodemographic and clinical data, including antipsychotic drug use, were collected, and the 18-item version of the Brief Psychiatric Rating Scale was administered. At discharge, data on antipsychotic drug therapy were collected. Prescribed daily doses were converted into multiples of the defined daily doses. Using a cut-off score of a prescribed daily dose/defined daily dose as a ratio of more than 1.5 both at admission and at discharge assessments, a total of 62 (15.4%) patients persistently received high antipsychotic dose. With less stringent criteria (prescribed daily dose/defined daily dose as a ratio of more than 2), however, only 4.4% of the entire sample was persistently exposed to high antipsychotic doses. Bootstrapped linear regression analysis revealed that positive symptoms were positively associated with high antipsychotic dose, whereas negative symptoms were negatively associated with high antipsychotic dose. Antipsychotic polypharmacy at admission was the strongest predictor of persistently receiving antipsychotic doses in excess of recommended levels. This study showed that the use of high antipsychotic dosing is not an occasional event. Clinicians should consider that concurrent prescribing of two or more antipsychotic agents increases the probability of administering excessive dosing in the long-term.

Association between the MnSOD Ala-9Val polymorphism and development of schizophrenia and abnormal involuntary movements in the Xhosa population

Reactive oxygen species (ROS)-mediated damage has been hypothesized to play a role in the development and poor outcome of schizophrenia, as well as the development of neuroleptic-induced abnormal involuntary movements. Recently, the functional polymorphism (Ala-9Val) in the manganese superoxide dismutase (MnSOD) gene (part of the antioxidant defense mechanism) was found to be associated with schizophrenia in a Turkish population. This study was aimed at replicating this finding in a Xhosa population. In addition, the role of Ala-9Val in abnormal involuntary movement and tardive dyskinesia development in the Xhosa population was also investigated. The schizophrenic patient group (n=286) and a healthy control group (n=243) were genotyped for the Ala-9Val polymorphism using heteroduplex-single stranded conformational polymorphism (HEX-SSCP) analysis. No significant difference in genotype or allele frequency could be observed between the schizophrenia and control group (P=0.294 and P=0.528 respectively). In addition no association could be found between the polymorphism and symptom severity (SANS and SAPS). The Xhosa schizophrenia patient group with abnormal involuntary movements (n=54) and a subgroup with tardive dyskinesia (n=30) was found to significantly differ in Ala-9Val genotype frequency (P=0.008 and P=0.011 respectively) compared to the Xhosa schizophrenia patient group without abnormal involuntary movements (n=204). However, no significant difference was found for the allele frequencies (P=0.955 and P=0.161). Further, using ANCOVA no association was found between AIMS score and genotype in the group with abnormal involuntary movements (P=0.1234). However, in the patient group with tardive dyskinesia an association was observed between genotype and AIMS score (P=0.0365). These results do not support a major role of the MnSOD Ala-9Val polymorphism in the development of schizophrenia or symptom severity in the Xhosa population. Yet it seems to be involved in the development of abnormal involuntary movements and tardive dyskinesia and may even modulate the severity of tardive dyskinesia.