Tardive dyskinesia associated with higher mortality in psychiatric patients: results of a meta-analysis of seven independent studies

Multiple therapies relieve long-term tardive dyskinesia in a patient with chronic schizophrenia: A case report

BACKGROUND

Tardive dyskinesia (TD) is a serious and disabling movement disorder; it impairs social function and quality of life and increases the mortality rate. TD is usually induced by the use of antipsychotic drugs; however, the underlying mechanism remains unclear. Pharmacotherapy of TD includes cholinergic drugs, benzodiazepines, ginkgo biloba extract (GBE), antioxidants, amantadine, propanolol, botulinum toxin, valbenazine, and deutetrabenazine, whereas the non-pharmacotherapy approach includes modified electroconvulsive therapy (MECT) and deep brain stimulation. We successfully treated a chronic schizophrenia patient with comorbid long-term severe TD using deutetrabenazine, clozapine, and MECT.

CASE SUMMARY

A 69-year-old woman who was diagnosed as having schizophrenia 16 years ago developed severe TD after 6-mo prescription of risperidone oral solution. Her TD symptoms did not resolve despite various treatments, such as GBE, vitamin E, trihexyphenidyl, promethazine, benzodiazepines, and switching to quetiapine and olanzapine. After admission, she was given deutetrabenazine 6 mg bid. Her buccal tremor was slightly resolved 3 d later; however, her tongue remained protruded and could not be retracted. Quetiapine was switched to clozapine on day 4, and the buccal tremor remarkably resolved, and the tongue could be retracted into the mouth from day 6 onward. After three sessions of MECT, the buccal tremor resolved further. Since then, she has been able to take a semifluid diet, and her quality of life improved remarkably during 6 mo of follow-up.

CONCLUSION

TD is a serious condition which could be caused by antipsychotic medications; however, the best strategy against TD is prevention and monitoring during using antipsychotics. For patients with TD caused by antipsychotic medication use, multiple measures should be considered like switching to clozapine, adjunction with deutetrabenazine, or even MECT.

Sex difference in association between tardive dyskinesia and cognitive deficits in patients with chronic schizophrenia

BACKGROUND

Tardive dyskinesia (TD), a side effect due to long-term use of antipsychotic medication, is associated with cognitive impairment. Several studies have found sex differences in cognitive impairment in schizophrenia patients, while whether there are sex differences in cognitive performance in schizophrenia patients with TD has not been reported.

METHODS

A total of 496 schizophrenia inpatients and 362 healthy controls were recruited for this study. We used the Positive and Negative Syndrome Scale (PANSS) to assess patients' psychopathological symptoms and the Abnormal Involuntary Movement Scale (AIMS) to assess the severity of TD. Cognitive function was measured in 313 of these inpatients and 310 of healthy controls using the Repeatable Battery for Assessment of Neuropsychological Status (RBANS).

RESULTS

Patients with schizophrenia performed worse in all cognitive domains than healthy controls(all p < 0.001). Compared to patients without TD, patients with TD had higher PANSS total, PANSS negative symptom subscale and AIMS scores (all p < 0.001), while RBANS total, visuospatial/constructional and attention subscale scores were significantly lower (all p < 0.05). In addition, the visuospatial/constructional and attention indices remained significantly lower in male patients with TD than those without TD (both p < 0.05), but these results were not observed in female patients. Moreover, visuospatial/constructional and attention indices were negatively correlated with total AIMS scores only in male patients (both p < 0.05).

CONCLUSION

Our results suggest that there may be sex differences in cognitive impairment in schizophrenia patients with comorbid TD, indicating that female gender may have a protective effect on cognitive impairment in schizophrenia patients caused by TD.

[Tardive dyskinesia]

Tardive dyskinesia (TD) is a delayed, often irreversible iatrogenic movement disorder caused by long-term use of that dopamine receptors blocking drugs. Prevention of TD is paramount, and clinicians should follow best practice recommendations for prescribing antipsychotics, as well as reduction the using of dopamine receptor blocking drugs for non-psychiatric prescriptions. Replacement of antipsychotics with lower affinity for D2 receptors drugs, addition of VMAT2 (tetrabenazine), botulinum therapy, amantadine may be effective. In detection and incurable cases, the possibility of neuromodulation of brain structures should be considered. Most methods for testing TD currently have an insufficient level of evidence, although they include recommendations from professional communities. There is a great need for new clinical trials.

Movement Disorders and Mortality in Severely Mentally Ill Patients: The Curacao Extrapyramidal Syndromes Study XIV

BACKGROUND AND HYPOTHESIS

There is a substantial gap in life expectancy between patients with severe mental illness (SMI) and the general population and it is important to understand which factors contribute to this difference. Research suggests an association between tardive dyskinesia (TD) and mortality; however, results are inconclusive. In addition, studies investigating associations between parkinsonism or akathisia and mortality are rare. We hypothesized that TD would be a risk factor for mortality in patients with SMI.

STUDY DESIGN

We studied a cohort of 157 patients diagnosed predominantly with schizophrenia on the former Netherlands Antilles. TD, parkinsonism, and akathisia were assessed with rating scales on eight occasions over a period of 18 years. Twenty-four years after baseline, survival status and if applicable date of death were determined. Associations between movement disorders and survival were analyzed using Cox regression. Sex, age, antipsychotics, antidepressants and benzodiazepines at each measurement occasion were tested as covariates.

STUDY RESULTS

Parkinsonism was a significant risk factor with an HR of 1.02 per point on the motor subscale of the Unified Parkinson's Disease Rating Scale (range 0-56). TD and akathisia were not significantly associated with mortality.

CONCLUSIONS

Parkinsonism may be an important risk factor for mortality in SMI patients. This finding calls for more follow-up and intervention studies to confirm this finding and to explore whether treatment or prevention of parkinsonism can reduce excess mortality.

Long-Term Deutetrabenazine Treatment for Tardive Dyskinesia Is Associated With Sustained Benefits and Safety: A 3-Year, Open-Label Extension Study

Background

Deutetrabenazine is a vesicular monoamine transporter 2 inhibitor approved for the treatment of tardive dyskinesia (TD) in adults. In two 12-week pivotal studies, deutetrabenazine demonstrated statistically significant improvements in Abnormal Involuntary Movement Scale (AIMS) scores, with favorable safety/tolerability in TD patients. This study reports long-term efficacy and safety of deutetrabenazine in a 3-year, single-arm, open-label extension (OLE) study.

Methods

Patients who completed the pivotal studies could enroll in this single-arm OLE study, titrating up to 48 mg/day based on dyskinesia control and tolerability. Efficacy was assessed based on change from baseline in total motor AIMS score, Clinical Global Impression of Change (CGIC) and Patient Global Impression of Change (PGIC), and quality of life (QOL) assessments. Safety evaluation included adverse event (AE) incidence, reported using exposure-adjusted incidence rates, and safety scales.

Results

343 patients enrolled in the study (6 patients were excluded). At Week 145 (mean dose: 39.4 ± 0.83 mg/day), mean ± SE change from baseline in total motor AIMS score was -6.6 ± 0.37 and 67% of patients achieved ≥50% improvement in total motor AIMS score. Based on CGIC and PGIC, 73% and 63% of patients achieved treatment success, respectively. QOL improvements were also observed. Deutetrabenazine was generally well tolerated, with low rates of mild-to-moderate AEs and no new safety signals; most safety scales remained unchanged over time.

Conclusions

Long-term deutetrabenazine treatment was associated with sustained improvement in AIMS scores, indicative of clinically meaningful long-term benefit, and was generally well tolerated. Results suggest deutetrabenazine may provide increasing benefit over time without increases in dose.

The Clinical and Economic Burden of Tardive Dyskinesia in Israel: Real-World Data Analysis

PURPOSE/BACKGROUND

Tardive dyskinesia (TD) is a hyperkinetic movement disorder caused by exposure to dopamine-receptor blockers. Data on TD burden in Israel are scarce. This analysis assesses the clinical and economic burden of TD in Israeli patients.

METHODS/PROCEDURES

This retrospective analysis used a national health plan database (Maccabi Healthcare Services), representing 25% of the Israeli population. The study included adults alive at index date with an International Classification of Diseases, Ninth Revision, Clinical Modification TD diagnosis before 2018 and more than or equal to 1-year enrollment before diagnosis. Tardive dyskinesia patients were matched to non-TD patients (1:3) by underlying psychiatric condition, birth year, and sex. Treatment patterns and 2018 annual health care resource utilization and costs were assessed.

FINDINGS/RESULTS

Of 454 TD patients alive between 2013 and 2018, 333 alive on January 1, 2018, were matched to 999 non-TD patients. At baseline, TD patients had lower socioeconomic status and higher proportion of chronic kidney disease and antipsychotic medication use; all analyses were adjusted accordingly. Tardive dyskinesia patients had significantly more visits to general physicians, neurologists, psychiatrists, physiotherapists, and emergency departments versus non-TD patients (all P < 0.05). Tardive dyskinesia patients also had significantly longer hospital stays than non-TD patients ( P = 0.003). Total healthcare and medication costs per patient were significantly higher in the TD versus non-TD population (US $11,079 vs US $7145, P = 0.018).

IMPLICATIONS/CONCLUSIONS

Israeli TD patients have higher clinical and economic burden than non-TD patients. Understanding real-world health care resource utilization and costs allows clinicians and decision makers to quantify TD burden and prioritize resources for TD patients' treatment.

Cost-effectiveness of valbenazine compared with deutetrabenazine for the treatment of tardive dyskinesia

AIMS

To evaluate clinical and economic outcomes associated with valbenazine compared with deutetrabenazine in patients with tardive dyskinesia (TD) using a model that accounts for multiple dimensions of patient health status.

MATERIALS AND METHODS

A discretely integrated condition event model was developed to evaluate the cost-effectiveness of treatment with valbenazine and deutetrabenazine in a synthetic cohort of 1,000 patients with TD who were receiving antipsychotic medication to treat an underlying psychiatric disorder. Clinical inputs were derived from relevant clinical trials or from publicly available sources. Patients were assessed over 1 year using ≥50% improvement from baseline in Abnormal Involuntary Movement Scale (AIMS) total score as the primary definition of response. Response at 1 year using Clinical Global Impression of Change (CGIC) score ≤2 was also assessed. Health outcomes included quality-adjusted life years (QALYs), life years, proportion responding to treatment at 1 year, and number of psychiatric relapses.

RESULTS

Regardless of the definition used for response, patients treated with valbenazine were more likely to have responded to treatment at 1 year, lived longer, and accrued more QALYs than patients who received deutetrabenazine. Using the AIMS response criterion, the incremental cost-effectiveness ratio was $9,951/QALY for valbenazine compared with deutetrabenazine. By comparison, using the CGIC response criterion valbenazine dominated deutetrabenazine with valbenazine-treated patients accumulating more QALYs (3.4 vs 3.3 years) and incurring lower lifetime costs ($252,311 vs $283,208) than deutetrabenazine-treated patients.

LIMITATIONS

There are no head-to-head trials of valbenazine and deutetrabenazine, so probabilities of response used in the model were calculated based on an indirect treatment comparison of results from individual trials with one drug or the other, using only those metrics reported across trials.

CONCLUSIONS

In patients with TD, treatment with valbenazine is highly cost-effective compared with deutetrabenazine.

Prevalence of Extrapyramidal Symptoms in In-Patients With Severe Mental Illnesses: Focus on Parkinsonism

Patients with severe mental illnesses may present extrapyramidal symptoms as part of a concomitant neurological disorder or secondary to medications. Extrapyramidal symptoms are frequently unrecognized, have negative consequences for adherence to treatment, negatively affect quality of life and can induce stigma. We estimated and correlated with demographic and clinical variables prevalence of extrapyramidal symptoms in in-patients with severe mental illnesses. Additionally we evaluated ¹²³I-FP-CIT SPECT binding to striatal dopamine transporter in subjects with clinical manifestations suggestive of Parkinson's Disease and recorded therapeutic management and clinical evolution for 6-months. Extrapyramidal symptoms were present in 144 out of 285 patients (50.5%), mainly tremor (94 patients, 33%). There were 38 patients (13.3%) with parkinsonism and they had older age, more medical comorbidities and medical treatments. In 15/38 patients striatal dopamine transporter binding was abnormal resulting in dose reduction or change of psychotropic drugs as well as combination with antiparkinson therapy. Our study confirmed the clinical and epidemiological relevance of extrapyramidal symptoms among inpatients with severe mental illnesses. A small percentage of patients with extrapyramidal symptoms had features compatible with possible diagnosis of Parkinson's Disease. ¹²³I-FP-CIT SPECT was useful to identify dopaminergic dysfunction and initiate dopamine replacement therapy.

Rethinking the risks and benefits of long-term maintenance in schizophrenia

This review addresses the risks and benefits of long-term maintenance antipsychotic treatment for patients that extends beyond two years. It focuses on framing discussions with patients who are recovering from a first episode. For these patients the evidence strongly supports the benefits over the risk for the first two years. However, both the clinical side effects of antipsychotics and the possible long-term effects of dopamine blocking drugs on the brain require a more nuanced discussion beyond this initial period. In most cases, the decision will be to continue antipsychotics but to consider strategies for mitigating the risks of drugs. This review provides information about the relative risks of dose reduction and intermittent treatment.

The genetics of drug-related movement disorders, an umbrella review of meta-analyses

This umbrella review investigates which genetic factors are associated with drug-related movement disorders (DRMD), in an attempt to provide a synthesis of published evidence of candidate-gene studies. To identify all relevant meta-analyses, a literature search was performed. Titles and abstracts were screened by two authors and the methodological quality of included meta-analyses was assessed using 'the assessment of multiple systematic reviews' (AMSTAR) critical appraisal checklist. The search yielded 15 meta-analytic studies reporting on genetic variations in 10 genes. DRD3, DRD2, CYP2D6, HTR2A, COMT, HSPG2 and SOD2 genes have variants that may increase the odds of TD. However, these findings do not concur with early genome-wide association studies. Low-power samples are susceptible to 'winner's curse', which was supported by diminishing meta-analytic effects of several genetic variants over time. Furthermore, analyses pertaining to the same genetic variant were difficult to compare due to differences in patient populations, methods used and the choice of studies included in meta-analyses. In conclusion, DRMD is a complex phenotype with multiple genes that impact the probability of onset. More studies with larger samples using other methods than by candidate genes, are essential to developing methods that may predict the probability of DRMD. To achieve this, multiple research groups need to collaborate and a DRMD genetic database needs to be established in order to overcome winner's curse and publication bias, and to allow for stratification by patient characteristics. These endeavours may help the development of a test with clinical value in the prevention and treatment of DRMD.

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.

Association of antipsychotic treatment switching in patients with schizophrenia, bipolar, and major depressive disorders

Aims: To evaluate the association of relapse and healthcare resource utilization in patients with schizophrenia (SZ), bipolar disorder (BD), or major depressive disorder (MDD) who switched antipsychotic medication versus those who did not.Materials and methods: Medicaid claims from six US states spanning six years were retrospectively analyzed for antipsychotic switching versus non-switching. For all patients with SZ, BD, or MDD, and for the subset of patients who also had ≥1 extrapyramidal symptoms (EPS) diagnosis at baseline, times to the following outcomes were analyzed: underlying disease relapse, other psychiatric relapse, all-cause emergency room (ER) visit, all-cause inpatient (IP) admission, and EPS diagnosis.Results: Switchers (N = 10,548) had a shorter time to disease relapse, other psychiatric relapse, IP admissions, ER visits, and EPS diagnosis (all, log-rank p < .001) than non-switchers (N = 31,644). Switchers reached the median for IP admission (21.50 months) vs non-switchers (not reached) and for ER visits (switchers, 9.07 months; non-switchers, 13.35 months). For disease relapse, other psychiatric relapse, and EPS diagnosis, <50% of patients had an event during the two-year study period. Subgroup analysis of those with ≥1 EPS diagnosis revealed similar associations.Limitations: Only association, not causation, may be inferred, and there may be differences between the patient groups in parameters not evaluated.Conclusions: These results show that disease and other psychiatric relapse, all-cause ER visits, IP admissions, and EPS diagnosis occurred earlier for patients who switched antipsychotics than for those who did not, suggesting that switching is associated with an increased risk of relapse in patients with SZ, BD, and MDD. This may be attributed to more-severely ill patients being less responsive than those with less-severe illness, which, in turn, may require more episodes of switching.

[Antipsychotic-induced motor symptoms in schizophrenic psychoses-Part 3 : Tardive dyskinesia]

The treatment of schizophrenic psychoses with antipsychotic drugs (AP) is often associated with an increased risk of delayed occurrence of antipsychotic-associated movement disorders. Persistence and chronicity of such symptoms are very frequent. The risk of developing tardive dyskinesia (TD) is associated with the pharmacological effect profile of a particular AP, with treatment duration and age. This systematic review article summarizes the current study situation on prevalence, risk factors, prevention and treatment options and instruments for early prediction of TD in schizophrenic psychoses. The current data situation on treatment strategies for TD is very heterogeneous. For the treatment of TD there is preliminary evidence for reduction or discontinuation of the AP, switching to clozapine, administration of benzodiazepines (clonazepam) and treatment with vesicular monoamine transporter (VMAT2) inhibitors, ginkgo biloba, amantadine or vitamin E. Although TD can be precisely diagnosed it cannot always be effectively treated. Early detection and early treatment of TD can have a favorable influence on the prognosis and the clinical outcome.

Health Care Resource Utilization and Costs for Patients with Tardive Dyskinesia

BACKGROUND

Tardive dyskinesia (TD) is an often-irreversible movement disorder affecting any part of the body. Patients experience debilitating symptoms that lower quality of life and increase mortality. Prolonged exposure to dopamine antagonists, which are frequently prescribed for psychiatric disorders as neuroleptic (antipsychotic) drugs, is a common cause of TD. The estimated prevalence of TD is 20%-50% among patients on antipsychotics, and the reported incidence of TD ranges from < 1% to 42%, depending on the antipsychotics studied. However, there are few real-world studies examining health care utilization and the economic burden of TD.

OBJECTIVE

To assess health care utilization and costs in a sample of patients with TD from the commercially insured and Medicare supplemental U.S.

POPULATIONS

METHODS

A retrospective analysis was conducted using Truven MarketScan Commercial and Medicare administrative claims data. Patients were included in the TD group if they had the first TD diagnosis (index date) between January 1, 2008, and September 30, 2014, with ≥ 1 inpatient or ≥ 2 outpatient nondiagnostic claims for TD (ICD-9-CM code 333.85). Patients without TD were randomly assigned an index date. Further inclusion criteria for all patients were ≥ 12 months of pre- and post-index medical and pharmacy continuous enrollment and no evidence of TD claims during the pre-index period. Patients with TD were directly matched to patients without TD within subgroups for schizophrenia, major depressive disorder, bipolar disorder, and other psychiatric disorders and propensity matched on other demographic and clinical factors. Descriptive statistics on the incidence of resource utilization and costs of health care were reported.

RESULTS

Of 3,397 patients with TD, 834 met the selection criteria and were matched to 834 non-TD controls. Patients with TD generally had significantly greater utilization during the 12 months after TD diagnosis than in the 12 months before TD diagnosis. Their rates for health care utilization and costs were also substantially higher than for those without TD. During the post-TD-diagnosis time, inpatient admissions (55.5% vs. 26.1%; P < 0.001) and emergency room visits (61.5% vs. 50.6%; P < 0.001) occurred more for patients with TD than for patients without TD. Total health care costs were significantly greater for patients with TD than for those without TD ($54,656 vs. $28,777; P < 0.001).

CONCLUSIONS

Patients diagnosed with TD demonstrate significantly higher health care utilization and costs compared with non-TD patients.

DISCLOSURES

This study was funded by Teva Pharmaceuticals (Petach Tikva, Israel). Truven Health Analytics, an IBM Watson Health Company, received payment from Teva Pharmaceuticals for the analysis in this study. Carroll is employed by Teva Pharmaceuticals and Irwin is employed by Truven Health Analytics, an IBM Watson Health Company.

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.

Risperidone as an effective choice for obsessive-compulsive symptoms and tardive dyskinesia in an Indian quadragenarian with schizo-obsessive disorder

Tardive dyskinesia (TD) is a chronic, stigmatizing side effect of typical and atypical antipsychotics that is often debilitating for the patient and resistant to treatment. Obsessive-compulsive symptoms (OCS) may arise at any stage of schizophrenia ranging from prodrome to posttreatment and carry a poor prognosis. Management of both the conditions is a challenging and often fatiguing task for the treating physician. We report a case of schizo-obsessive disorder in an Indian quadragenarian who had developed TD with olanzapine and had failed to show improvement with clozapine and quetiapine. The patient improved dramatically with risperidone. Our findings corroborate with previous literature which has shown risperidone to be effective in treatment of TD and obsessive symptoms, possibly due to its action on the serotonergic system. The authors conclude that risperidone is an effective choice to treat TD and comorbid OCS in patients with schizophrenia.

Systematic review of interventions for treating or preventing antipsychotic-induced tardive dyskinesia

BACKGROUND

Antipsychotic medication can cause tardive dyskinesia (TD) - late-onset, involuntary, repetitive movements, often involving the face and tongue. TD occurs in > 20% of adults taking antipsychotic medication (first-generation antipsychotics for > 3 months), with this proportion increasing by 5% per year among those who continue to use these drugs. The incidence of TD among those taking newer antipsychotics is not different from the rate in people who have used older-generation drugs in moderate doses. Studies of TD have previously been found to be limited, with no treatment approach shown to be effective.

OBJECTIVES

To summarise the clinical effectiveness and safety of treatments for TD by updating past Cochrane reviews with new evidence and improved methods; to undertake public consultation to gauge the importance of the topic for people living with TD/the risk of TD; and to make available all data from relevant trials.

DATA SOURCES

All relevant randomised controlled trials (RCTs) and observational studies.

REVIEW METHODS

Cochrane review methods, network meta-analysis (NMA).

DESIGN

Systematic reviews, patient and public involvement consultation and NMA.

SETTING

Any setting, inpatient or outpatient.

PARTICIPANTS

For systematic reviews, adults with TD who have been taking a stable antipsychotic drug dose for > 3 months.

INTERVENTIONS

Any, with emphasis on those relevant to UK NHS practice.

MAIN OUTCOME MEASURES

Any measure of TD, global assessments and adverse effects/events.

RESULTS

We included 112 studies (nine Cochrane reviews). Overall, risk of bias showed little sign of improvement over two decades. Taking the outcome of 'TD symptoms improved to a clinically important extent', we identified two trials investigating reduction of antipsychotic dose [n = 17, risk ratio (RR) 0.42, 95% confidence interval (CI) 0.17 to 1.04; very low quality]. Switching was investigated twice in trials that could not be combined (switching to risperidone vs. antipsychotic withdrawal: one RCT, n = 42, RR 0.45, 95% CI 0.23 to 0.89; low quality; switching to quetiapine vs. haloperidol: one RCT, n = 45, RR 0.80, 95% CI 0.52 to 1.22; low quality). In addition to RCTs, six observational studies compared antipsychotic discontinuation with decreased or increased dosage, and there was no clear evidence that any of these strategies had a beneficial effect on TD symptoms (very low-quality evidence). We evaluated the addition to standard antipsychotic care of several treatments, but not anticholinergic treatments, for which we identified no trials. We found no clear effect of the addition of either benzodiazepines (two RCTs, n = 32, RR 1.12, 95% CI 0.6 to 2.09; very low quality) or vitamin E (six RCTs, n = 264, RR 0.95, 95% CI 0.89 to 1.01; low quality). Buspirone as an adjunctive treatment did have some effect in one small study (n = 42, RR 0.53, 95% CI 0.33 to 0.84; low quality), as did hypnosis and relaxation (one RCT, n = 15, RR 0.45, 95% CI 0.21 to 0.94; very low quality). We identified no studies focusing on TD in people with dementia. The NMA model found indirect estimates to be imprecise and failed to produce useful summaries on relative effects of interventions or interpretable results for decision-making. Consultation with people with/at risk of TD highlighted that management of TD remains a concern, and found that people are deeply disappointed at the length of time it has taken researchers to address the issue.

LIMITATIONS

Most studies remain small and poorly reported.

CONCLUSIONS

Clinicians, policy-makers and people with/at risk of TD are little better informed than they were decades ago. Underpowered trials of limited quality repeatedly fail to provide answers.

FUTURE WORK

TD reviews have data from current trials extracted, tabulated and traceable to source. The NMA highlights one context in which support for this technique is ill advised. All relevant trials, even if not primarily addressing the issue of TD, should report appropriate binary outcomes on groups of people with this problem. Randomised trials of treatments for people with established TD are indicated. These should be large (> 800 participants), necessitating accrual through accurate local/national registers, including an intervention with acceptable treatments and recording outcomes used in clinical practice.

STUDY REGISTRATION

This study is registered as PROSPERO CRD4201502045.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Cholinergic medication for antipsychotic-induced tardive dyskinesia

BACKGROUND

Tardive dyskinesia (TD) remains a troublesome adverse effect of conventional antipsychotic (neuroleptic) medication. It has been proposed that TD could have a component of central cholinergic deficiency. Cholinergic drugs have been used to treat TD.

OBJECTIVES

To determine the effects of cholinergic drugs (arecoline, choline, deanol, lecithin, meclofenoxate, physostigmine, RS 86, tacrine, metoxytacrine, galantamine, ipidacrine, donepezil, rivastigmine, eptastigmine, metrifonate, xanomeline, cevimeline) for treating antipsychotic-induced TD in people with schizophrenia or other chronic mental illness.

SEARCH METHODS

An electronic search of the Cochrane Schizophrenia Group's Study-Based Register of Trials (16 July 2015 and April 2017) was undertaken. This register is assembled by extensive searches for randomised controlled trials in many electronic databases, registers of trials, conference proceedings and dissertations. References of all identified studies were searched for further trial citations.

SELECTION CRITERIA

We included reports identified by the search if they were of controlled trials involving people with antipsychotic-induced TD and chronic mental illness, who had been randomly allocated to either a cholinergic agent or to a placebo or no intervention. Two review authors independently assessed the methodological quality of the trials.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data and, where possible, estimated risk ratios (RR) or mean differences (MD), with 95% confidence intervals (CI). We analysed data on an intention-to-treat basis, with the assumption that people who left early had no improvement. We assessed risk of bias and created a 'Summary of findings' table using GRADE.

MAIN RESULTS

We included 14 studies investigating the use of cholinergic drugs compared with placebo published between 1976 and 2014. All studies involved small numbers of participants (five to 60 people). Three studies that investigated the new cholinergic Alzheimer drugs for the treatment of TD are new to this update. Overall, the risk of bias in the included studies was unclear, mainly due to poor reporting; allocation concealment was not described, generation of the sequence was not explicit, studies were not clearly blinded, we are unsure if data are incomplete, and data were often poorly or selectively reported.We are uncertain about the effect of new or old cholinergic drugs on no clinically important improvement in TD symptoms when compared with placebo; the quality of evidence was very low (RR 0.89, 95% CI 0.65 to 1.23; 27 people, 4 RCTs). Eight trials found that cholinergic drugs may make little or no difference to deterioration of TD symptoms (low-quality evidence, RR 1.11, 95% CI 0.55 to 2.24; 147 people). Again, due to very low-quality evidence, we are uncertain about the effects on mental state (RR 0.50, 95% CI 0.10 to 2.61; 77 people, 5 RCTs), adverse events (RR 0.56, 95% CI 0.15 to 2.14; 106 people, 4 RCTs), and leaving the study early (RR 1.09,95% CI 0.56 to 2.10; 288 people 12 RCTs). No study reported on social confidence, social inclusion, social networks, or personalised quality of life.

AUTHORS' CONCLUSIONS

TD remains a major public health problem. The clinical effects of both older cholinergic drugs and new cholinergic agents, now used for treating Alzheimer's disease, are unclear, as too few, too small studies leave many questions unanswered. Cholinergic drugs should remain of interest to researchers and currently have little place in routine clinical work. However, with the advent of new cholinergic agents now used for treating Alzheimer's disease, scope exists for more informative trials. If these new cholinergic agents are to be investigated for treating people with TD, their effects should be demonstrated in large well-designed, conducted and reported randomised trials.

Miscellaneous treatments for antipsychotic-induced tardive dyskinesia

BACKGROUND

Antipsychotic (neuroleptic) medication is used extensively to treat people with chronic mental illnesses. Its use, however, is associated with adverse effects, including movement disorders such as tardive dyskinesia (TD) - a problem often seen as repetitive involuntary movements around the mouth and face. This review, one in a series examining the treatment of TD, covers miscellaneous treatments not covered elsewhere.

OBJECTIVES

To determine whether drugs, hormone-, dietary-, or herb-supplements not covered in other Cochrane reviews on TD treatments, surgical interventions, electroconvulsive therapy, and mind-body therapies were effective and safe for people with antipsychotic-induced TD.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Study-Based Register of Trials including trial registers (16 July 2015 and 26 April 2017), inspected references of all identified studies for further trials and contacted authors of trials for additional information.

SELECTION CRITERIA

We included reports if they were randomised controlled trials (RCTs) dealing with people with antipsychotic-induced TD and schizophrenia or other chronic mental illnesses who remained on their antipsychotic medication and had been randomly allocated to the interventions listed above versus placebo, no intervention, or any other intervention.

DATA COLLECTION AND ANALYSIS

We independently extracted data from these trials and we estimated risk ratios (RR) or mean differences (MD), with 95% confidence intervals (CIs). We assumed that people who left early had no improvement. We assessed risk of bias and created 'Summary of findings' tables using GRADE.

MAIN RESULTS

We included 31 RCTs of 24 interventions with 1278 participants; 22 of these trials were newly included in this 2017 update. Five trials are awaiting classification and seven trials are ongoing. All participants were adults with chronic psychiatric disorders, mostly schizophrenia, and antipsychotic-induced TD. Studies were primarily of short (three to six6 weeks) duration with small samples size (10 to 157 participants), and most (61%) were published more than 20 years ago. The overall risk of bias in these studies was unclear, mainly due to poor reporting of allocation concealment, generation of the sequence, and blinding.Nineteen of the 31 included studies reported on the primary outcome 'No clinically important improvement in TD symptoms'. Two studies found moderate-quality evidence of a benefit of the intervention compared with placebo: valbenazine (RR 0.63, 95% CI 0.46 to 0.86, 1 RCT, n = 92) and extract of Ginkgo biloba (RR 0.88, 95% CI 0.81 to 0.96, 1 RCT, n = 157), respectively. However, due to small sample sizes we cannot be certain of these effects.We consider the results for the remaining interventions to be inconclusive: Low- to very low-quality evidence of a benefit was found for buspirone (RR 0.53, 95% CI 0.33 to 0.84, 1 RCT, n = 42), dihydrogenated ergot alkaloids (RR 0.45, 95% CI 0.21 to 0.97, 1 RCT, n = 28), hypnosis or relaxation, (RR 0.45, 95% CI 0.21 to 0.94, 1 study, n = 15), pemoline (RR 0.48, 95% CI 0.29 to 0.77, 1 RCT, n = 46), promethazine (RR 0.24, 95% CI 0.11 to 0.55, 1 RCT, n = 34), insulin (RR 0.52, 95% CI 0.29 to 0.96, 1 RCT, n = 20), branched chain amino acids (RR 0.79, 95% CI 0.63 to 1.00, 1 RCT, n = 52), and isocarboxazid (RR 0.24, 95% CI 0.08 to 0.71, 1 RCT, n = 20). There was low- to very low-certainty evidence of no difference between intervention and placebo or no treatment for the following interventions: melatonin (RR 0.89, 95% CI 0.71 to 1.12, 2 RCTs, n = 32), lithium (RR 1.59, 95% CI 0.79 to 3.23, 1 RCT, n = 11), ritanserin (RR 1.00, 95% CI 0.70 to 1.43, 1 RCT, n = 10), selegiline (RR 1.37, 95% CI 0.96 to 1.94, 1 RCT, n = 33), oestrogen (RR 1.18, 95% CI 0.76 to 1.83, 1 RCT, n = 12), and gamma-linolenic acid (RR 1.00, 95% CI 0.69 to 1.45, 1 RCT, n = 16).None of the included studies reported on the other primary outcome, 'no clinically significant extrapyramidal adverse effects'.

AUTHORS' CONCLUSIONS

This review has found that the use of valbenazine or extract of Ginkgo biloba may be effective in relieving the symptoms of tardive dyskinesia. However, since only one RCT has investigated each one of these compounds, we are awaiting results from ongoing trials to confirm these results. Results for the remaining interventions covered in this review must be considered inconclusive and these compounds probably should only be used within the context of a well-designed evaluative study.

Antipsychotic reduction and/or cessation and antipsychotics as specific treatments for tardive dyskinesia

BACKGROUND

Since the 1950s antipsychotic medication has been extensively used to treat people with chronic mental illnesses such as schizophrenia. These drugs, however, have also been associated with a wide range of adverse effects, including movement disorders such as tardive dyskinesia (TD) - a problem often seen as repetitive involuntary movements around the mouth and face. Various strategies have been examined to reduce a person's cumulative exposure to antipsychotics. These strategies include dose reduction, intermittent dosing strategies such as drug holidays, and antipsychotic cessation.

OBJECTIVES

To determine whether a reduction or cessation of antipsychotic drugs is associated with a reduction in TD for people with schizophrenia (or other chronic mental illnesses) who have existing TD. Our secondary objective was to determine whether the use of specific antipsychotics for similar groups of people could be a treatment for TD that was already established.

SEARCH METHODS

We updated previous searches of Cochrane Schizophrenia's study-based Register of Trials including the registers of clinical trials (16 July 2015 and 26 April 2017). We searched references of all identified studies for further trial citations. We also contacted authors of trials for additional information.

SELECTION CRITERIA

We included reports if they assessed people with schizophrenia or other chronic mental illnesses who had established antipsychotic-induced TD, and had been randomly allocated to (a) antipsychotic maintenance versus antipsychotic cessation (placebo or no intervention), (b) antipsychotic maintenance versus antipsychotic reduction (including intermittent strategies), (c) specific antipsychotics for the treatment of TD versus placebo or no intervention, and (d) specific antipsychotics versus other antipsychotics or versus any other drugs for the treatment of TD.

DATA COLLECTION AND ANALYSIS

We independently extracted data from these trials and estimated risk ratios (RR) or mean differences (MD), with 95% confidence intervals (CI). We assumed that people who dropped out had no improvement.

MAIN RESULTS

We included 13 RCTs with 711 participants; eight of these studies were newly included in this 2017 update. One trial is ongoing.There was low-quality evidence of a clear difference on no clinically important improvement in TD favouring switch to risperidone compared with antipsychotic cessation (with placebo) (1 RCT, 42 people, RR 0.45 CI 0.23 to 0.89, low-quality evidence). Because evidence was of very low quality for antipsychotic dose reduction versus antipsychotic maintenance (2 RCTs, 17 people, RR 0.42 95% CI 0.17 to 1.04, very low-quality evidence), and for switch to a new antipsychotic versus switch to another new antipsychotic (5 comparisons, 5 RCTs, 140 people, no meta-analysis, effects for all comparisons equivocal), we are uncertain about these effects. There was low-quality evidence of a significant difference on extrapyramidal symptoms: use of antiparkinsonism medication favouring switch to quetiapine compared with switch to haloperidol (1 RCT, 45 people, RR 0.45 CI 0.21 to 0.96, low-quality evidence). There was no evidence of a difference for switch to risperidone or haloperidol compared with antipsychotic cessation (with placebo) (RR 1 RCT, 48 people, RR 2.08 95% CI 0.74 to 5.86, low-quality evidence) and switch to risperidone compared with switch to haloperidol (RR 1 RCT, 37 people, RR 0.68 95% CI 0.34 to 1.35, very low-quality evidence).Trials also reported on secondary outcomes such as other TD symptom outcomes, other adverse events outcomes, mental state, and leaving the study early, but the quality of the evidence for all these outcomes was very low due mainly to small sample sizes, very wide 95% CIs, and risk of bias. No trials reported on social confidence, social inclusion, social networks, or personalised quality of life, outcomes that we designated as being important to patients.

AUTHORS' CONCLUSIONS

Limited data from small studies using antipsychotic reduction or specific antipsychotic drugs as treatments for TD did not provide any convincing evidence of the value of these approaches. There is a need for larger trials of a longer duration to fully investigate this area.

Clinical risk factors for the development of tardive dyskinesia

BACKGROUND

Tardive dyskinesia (TD) is a severe condition that can affect almost 1 out of 4 patients on current or previous antipsychotic treatment, including both first-generation antipsychotics (FGAs) and second-generation antipsychotics (SGAs). While two novel vesicular monoamine transporter inhibitors, deutetrabenazine and valbenazine, have shown acute efficacy for TD, the majority of patients do not remit, and TD appears to recur once treatment is withdrawn. Hence, prevention of TD remains a crucial goal.

METHODS

We provide a clinically oriented overview of risk factors for TD, dividing them into patient-, illness- and treatment-related variables, as well as nonmodifiable and modifiable factors.

RESULTS

Unmodifiable patient-related and illness-related risk factors for TD include older age, female sex, white and African descent, longer illness duration, intellectual disability and brain damage, negative symptoms in schizophrenia, mood disorders, cognitive symptoms in mood disorders, and gene polymorphisms involving antipsychotic metabolism and dopamine functioning. Modifiable comorbidity-related and treatment-related factors include diabetes, smoking, and alcohol and substance abuse, FGA vs SGA treatment, higher cumulative and current antipsychotic dose or antipsychotic plasma levels, early parkinsonian side effects, anticholinergic co-treatment, akathisia, and emergent dyskinesia.

DISCUSSION

Clinicians using dopamine antagonists need to consider risk factors for TD to minimize TD and its consequences.

Non-antipsychotic catecholaminergic drugs for antipsychotic-induced tardive dyskinesia

BACKGROUND

Tardive dyskinesia (TD) is a disabling movement disorder associated with the prolonged use of antipsychotic medication. Several strategies have been examined in the treatment of TD. Currently, however, there is no clear evidence of the effectiveness of these drugs in TD and they have been associated with many side effects. One particular strategy would be to use pharmaceutical agents which are known to influence the catecholaminergic system at various junctures.

OBJECTIVES

1. To determine the effects of any of the following drugs for antipsychotic-induced TD in people with schizophrenia or other chronic mental illnesses.i. Drugs which influence the noradrenergic system.ii. Dopamine receptor agonists.iii. Dopamine receptor antagonists.iv. Dopamine-depletor drugs.v. Drugs that increase the production or release of dopamine.2. To examine whether any improvement occurred with short periods of intervention (less than 6 weeks) and, if this did occur, whether this effect was maintained at longer periods of follow-up.3. To examine if there was a differential effect for the various compounds.4. To examine whether the use of non-antipsychotic catecholaminergic drugs are most effective in those with more recent onset TD (less than five years).

SEARCH METHODS

We retrieved 712 references from searching the Cochrane Schizophrenia Group Trials Register (July 2015 and April 2017). We also inspected references of all identified studies for further trials and contacted authors of trials for additional information.

SELECTION CRITERIA

We selected studies if they were randomised controlled trials focusing on people with schizophrenia or other chronic mental illnesses and antipsychotic-induced tardive dyskinesia. We compared the use of catecholaminergic interventions versus placebo, no intervention, or any other intervention for the treatment of antipsychotic-induced tardive dyskinesia.

DATA COLLECTION AND ANALYSIS

We independently extracted data from these trials and we estimated risk ratios (RRs) with 95% confidence intervals (CIs). We assumed that people who left the studies early had no improvement.

MAIN RESULTS

There are 10 included trials (N = 261) published between 1973 and 2010; eight are new from the 2015 and 2017 update searches. Forty-eight studies are excluded. Participants were mostly chronically mentally ill inpatients in their 50s, and studies were primarily of short (2 to 6 weeks) duration. The overall risk of bias in these studies was unclear, mainly due to poor reporting of allocation concealment and generation of the sequence. Studies were also not clearly blinded and we are unsure if data are incomplete or selectively reported, or if other biases were operating.One small, three-arm trial found that both alpha-methyldopa (N = 20; RR 0.33, 95% CI 0.14 to 0.80; low-quality evidence) and reserpine (N = 20; RR 0.52 95% CI 0.29 to 0.96; low-quality evidence) may lead to a clinically important improvement in tardive dyskinesia symptoms compared with placebo after 2 weeks' treatment, but found no evidence of a difference between alpha-methyldopa and reserpine (N = 20; RR 0.60, 95% CI 0.19 to 1.86; very low quality evidence). Another small trial compared tetrabenazine and haloperidol after 18 weeks' treatment and found no evidence of a difference on clinically important improvement in tardive dyskinesia symptoms (N = 13; RR 0.93, 95% CI 0.45 to 1.95; very low quality evidence). No study reported on adverse events.For remaining outcomes there was no evidence of a difference between any of the interventions: alpha-methyldopa versus placebo for deterioration of tardive dyskinesia symptoms (1 RCT; N = 20; RR 0.33, 95% CI 0.02 to 7.32; very low quality evidence), celiprolol versus placebo for leaving the study early (1 RCT; N = 35; RR 5.28, 95% CI 0.27 to 102.58; very low quality evidence) and quality of life (1 RCT; N = 35; RR 0.87, 95% CI 0.68 to 1.12; very low quality evidence), alpha-methyldopa versus reserpine for deterioration of tardive dyskinesia symptoms (1 RCT; N = 20; not estimable, no reported events; very low quality evidence), reserpine or carbidopa/levodopa versus placebo for deterioration of tardive dyskinesia symptoms (2 RCTs; N = 37; RR 1.18, 95% CI 0.35 to 3.99; very low quality evidence), oxypertine versus placebo for deterioration of mental state (1 RCT; N = 42; RR 2.20, 95% CI 0.22 to 22.45; very low quality evidence), dopaminergic drugs (amantadine, bromocriptine, tiapride, oxypertine, carbidopa/levodopa) versus placebo for leaving the study early (6 RCTs; N = 163; RR 1.29, 95% CI 0.65 to 2.54; very low quality evidence), and tetrabenazine versus haloperidol for deterioration of tardive dyskinesia symptoms (1 RCT; N = 13; RR 1.17, 95% CI 0.09 to 14.92) and leaving the study early (1 RCT; N = 13; RR 0.23, 95% CI 0.01 to 4.00).

AUTHORS' CONCLUSIONS

Although there has been a large amount of research in this area, many studies were excluded due to inherent problems in the nature of their cross-over designs. Usually data are not reported before the cross-over and the nature of TD and its likely response to treatments make it imprudent to use this data. The review provides little usable information for service users or providers and more well-designed and well-reported studies are indicated.

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.

Tardive dyskinesia (syndrome): Current concept and modern approaches to its management

Tardive dyskinesia is a serious, disabling and potentially permanent, neurological hyperkinetic movement disorder that occurs after months or years of taking psychotropic drugs. The pathophysiology of tardive dyskinesia is complex, multifactorial and still not fully understood. A number of drugs were tried for the management of this motor disturbance, yet until now no effective and standard treatment has been found. It is very disappointing to realize that the introduction of antipsychotics from the second generation has not significantly decreased the prevalence and incidence of tardive dyskinesia. Therefore, the management of this motor disturbance remains an actual topic as well as a challenge for clinicians. This review summarizes recent relevant publications concerning the treatment of tardive dyskinesia.

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.

Association of the dopamine β-hydroxylase 19 bp insertion/deletion polymorphism with positive symptoms but not tardive dyskinesia in schizophrenia

OBJECTIVE

Overactivity of dopaminergic neurotransmission is a putative mechanism of tardive dyskinesia (TD). Dopamine beta-hydroxylase (DBH) is a key enzyme in the conversion of dopamine to norepinephrine, and plasma DBH activity is altered in TD patients. This study examined whether the functional DBH 5'-Ins/Del polymorphism was associated with TD severity in Chinese patients with schizophrenia.

METHODS

We compared the rate of this polymorphism in patients with (n = 312) and without TD (n = 435), and healthy controls (n = 625). The severity of TD was assessed using the Abnormal Involuntary Movement Scale (AIMS) and psychopathology using the Positive and Negative Syndrome Scale (PANSS).

RESULTS

There were no significant differences in the distribution of the allele and genotype frequencies between the patients and controls, or between the patients with and without TD. Also, there was no significant difference in the AIMS total score between the three genotype groups. However, the PANSS positive symptom subscore was significantly higher in patients with Del/Del genotype (13.2 ± 5.2) than those with Ins/Del (11.2 ± 4.9) and Ins/Ins (11.1 ± 3.1) genotypes (both p < 0.05).

CONCLUSION

These results suggest that although the DBH 5'-Ins/Del polymorphism was not associated with susceptibility to TD in patients with schizophrenia, it might be related to positive symptoms of schizophrenia.

[Tardive dyskinesia induced by classical antipsychotic drugs: a Tunisian sample of schizophrenics]

INTRODUCTION

The term tardive dyskinesia (TD) is used to describe abnormal movement, primarily associated with typical antipsychotic drugs, which are used to treat psychotic states such as schizophrenia. TD is characterised by repetitive involuntary purposeless muscle contractions that force parts of the body into abnormal, and sometimes painful, movements or postures. These movements are involuntary and are difficult or impossible to control. TD usually begins with the face, mouth, lips and tongue, and includes grimacing, lip-smacking, tongue movements and rapid blinking. It may also involve the rest of the body and produce involuntary gestures, tics and writhing movements. TD is severe physically and socially disabling. Schizophrenia is thought to be the psychiatric diagnosis the most frequently associated with TD.

MATERIALS AND METHODS

The purpose of this article is to study the characteristics of TD in a Tunisian sample of 157 schizophrenics. A variety of demographic and clinical information was obtained by a questionnaire. Diagnoses of schizophrenia and TD were determined by using DSM-VI-R criteria. TD was assessed using the Abnormal Involuntary Movements Scale (AIMS).

RESULTS

The average age in this sample was 37 ± 6 years. The intermediate duration of evolution of the disease was 8 ± 3 years with a medium full number of hospitalizations of 4 ± 3. We found 58% of the paranoid sub-type. The intermediate duration of exposure to classical neuroleptics was 7 ± 3 years. The average of daily neuroleptic amount was 572.9 ± 145.3 equivalent milligrams of chlorpromazine. Extended release antipsychotics were used in 64.3% of cases, with fluphenazine deaconate in 90% and haloperidol deaconate in 10%. Anticholinergics were used by 74.5% of patients, with use of biperidene in 96% of cases. Therapeutic observance was good in 89.2% of patients. The prevalence of TD was an estimated 35%. The average of AIMS score was 17 ± 9, with a minimal score of 3 and a maximal one of 34. The distribution of patients according to severity found a prevalence of 52.7% of subjects with moderate TD, 38.2% with light TD and 9.1% with severe TD. The distribution of patients according to type, according to DSM-IV criteria, found 78.4% of cases with choreiform TD, 17.5% of cases with athetosic TD and 4.1% of cases with rhythmic TD. The intermediate duration of evolution of TD was estimated at 18 ± 6 months with a minimal duration of 3 months and a maximum of 72 months. The distribution of subjects according to duration of evolution of TD found that approximately three quarter of patients presented with TD that had evolved since one duration, lower or equal to one year. The average age of patients at the moment of installation of TD was estimated at 36 ± 6 years with 22 years as a minimal and 46 years as a maximal age. Among them, 81.8% of patients were aged over 30 at the time of the installation of TD.

CONCLUSION

The majority of patients with schizophrenia in Tunisia are still treated with typical antipsychotic drugs, and that's why the prevalence of TD remains relatively high.

All-cause mortality and medication risk factors in schizophrenia: a prospective cohort study

BACKGROUND

It is well established that persons with schizophrenia have high mortality rates. There is conflicting evidence that antipsychotic and perhaps other medications routinely used to treat schizophrenia contribute to mortality risk.

METHODS

A health insurer database was used to examine schizophrenia diagnosis and mortality in 2008. Information from the period 2006-2008 was used to analyze demographics and medication prescriptions. The risk set composed of patients with schizophrenia using an antipsychotic (n = 7415) and a group of randomly chosen control subjects (n = 97,726).

RESULTS

The mortality risk for having a diagnosis of schizophrenia and using an antipsychotic versus the random control group was a hazard ratio (HR) of 2.6; 95% CI, 2.0-3.2. Over the 3-year period, age, receiving a first-generation antipsychotic, and the use of a mood stabilizer were associated with a higher risk of mortality: HR, 1.06; 95% CI, 1.04-1.08; HR, 2.36; 95% CI, 1.38-4.04; and HR, 8.42; 95% CI, 3.06-24.07, respectively.

CONCLUSION

Patients with schizophrenia have higher mortality rates than normal controls. The type of antipsychotic and concomitant medication can affect mortality rates in schizophrenia.

Long-stay psychiatric patients: a prospective study revealing persistent antipsychotic-induced movement disorder

OBJECTIVE

The purpose of this study was to assess the frequency of persistent drug-induced movement disorders namely, tardive dyskinesia (TD), parkinsonism, akathisia and tardive dystonia in a representative sample of long-stay patients with chronic severe mental illness.

METHOD

Naturalistic study of 209, mainly white, antipsychotic-treated patients, mostly diagnosed with psychotic disorder. Of this group, the same rater examined 194 patients at least two times over a 4-year period, with a mean follow-up time of 1.1 years, with validated scales for TD, parkinsonism, akathisia, and tardive dystonia.

RESULTS

The frequencies of persistent movement disorders in the sample were 28.4% for TD, 56.2% for parkinsonism, 4.6% for akathisia and 5.7% for tardive dystonia. Two-thirds of the participants displayed at least one type of persistent movement disorder.

CONCLUSIONS

Persistent movement disorder continues to be the norm for long-stay patients with chronic mental illness and long-term antipsychotic treatment. Measures are required to remedy this situation.

Smoking and tardive dyskinesia in male patients with chronic schizophrenia

Interactions between smoking and movement disorders include the contrasting associations of more cigarette smoking with reductions in Parkinson's disease and increases in tardive dyskinesia (TD) symptoms. Here we examine the relationship between smoking and TD in a large sample of inpatients with schizophrenia. We used cross-sectional naturalistic methods to analyze the prevalence and severity of neuroleptic-induced TD in relation to cigarette smoking among 764 male chronic and medicated inpatients meeting DSM-IV criteria for schizophrenia. We administered a detailed questionnaire including general information, medical and psychological conditions, and smoking behaviors. We evaluated TD severity using the abnormal involuntary movement scale (AIMS) and psychopathology using the Positive and Negative Syndrome Scale (PANSS). The main statistical analyses used cross-tabulations for the prevalence of TD by smoking and multivariate regression analyses for continuous measures (AIMS and PANSS). We found that the prevalence of TD did not significantly differ between smokers (41%=237/578) and non-smokers (37%=69/186). Secondary outcomes showed a significant association between the AIMS total score and age, duration of illness and hospitalization times. Thus, smoking was not associated with TD in male Chinese schizophrenics, but consistent with previous reports, older patients with a longer duration of illness and more hospitalizations showed greater severity of TD.

Ethical and Policy Considerations in the Application of Pharmacogenomic Testing for Tardive Dyskinesia: Case Study of the Dopamine D3 Receptor

Tardive dyskinesia (TD) is a serious adverse effect often associated with the first generation antipsychotic medications used in the management of mental health disorders such as schizophrenia. Pharmacogenomics is the study of human genomic variation in relation to individual and population variability in medication response and side effects. Neuropsychiatry is one of the clinical domains in which pharmacogenomic approaches have been extensively studied. In the late 1990s, the Glycine9 (Gly9) allele of the Serine-9-Glycine (Ser9Gly) polymorphism in dopamine D3 receptor gene (DRD3) was found to be associated with both a liability to, and worsened severity of, TD in schizophrenic patients treated with typical antipsychotics. This initial discovery has been subsequently replicated and testing for the Ser9Gly polymorphism has now become commercially available. The question that currently presents itself is whether its use should be encouraged for patients who may be prescribed a typical or atypical antipsychotic medication. However, the translation of this new technology to clinical practice presents multiple social, ethical and policy challenges. Though pharmacogenomic testing holds much promise in this scenario, many important questions remain to be answered before its widespread use can be medically and ethically justified. This article highlights the key advances in our understanding of the role of human genetic variation in the D3 receptor in relation to TD. Then, issues of uncertainty, consent, confidentiality, and access are considered with respect to the use of DRD3 polymorphism testing in risk stratification for susceptibility to tardive dyskinesia. We propose three recommendations that may help bring this technology into the clinic: 1) prospective pharmacogenomic studies of DRD3 polymorphism and TD risk should be conducted; 2) the design of such studies should be influenced by scientists, ethicists and policy makers to protect potentially vulnerable patients; and 3) appropriate knowledge transfer to front-line health care workers must take place.

Incidence and persistence of tardive dyskinesia and extrapyramidal symptoms in schizophrenia

Although it has been suggested that second-generation antipsychotics (SGA) may reduce the rate of prevalent tardive dyskinesia (TD), little is known about the incidence and outcome of TD in those exposed exclusively to SGA. The incidence and subsequent persistence of TD and extrapyramidal symptoms (EPS) was calculated in a cohort of patients with schizophrenia treated predominantly with SGA. This cohort of more than 10,000 patients with schizophrenia was seen six times over a period of two years. Dichotomous measures of EPS and TD were used to calculate the yearly incidence rates of TD and EPS as well as their subsequent cumulative persistence rate in a subset of 9104 and 6285 patients at risk for TD and EPS, respectively. Of 9104 individuals who did not present with TD at baseline, 138 developed TD, yielding a TD incidence rate of 0.74% (95% CI: 0.62, 0.87) and a subsequent cumulative persistence rate of 80%. Of 6285 individuals without EPS at baseline, 464 developed EPS yielding an incidence rate of 3.7% (95% CI: 3.4, 4.0) and a subsequent cumulative persistence rate of 82%. Incidence rates of TD and EPS may be low in the SGA era. However, once emerged, these disorders prove persistent, suggesting strong moderators effects of underlying predisposing factors.

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.

Mortality and tardive dyskinesia: long-term study using the US National Death Index

BACKGROUND

Whether the development of tardive dyskinesia leads to an increase in mortality is still unclear.

AIMS

To explore the relationship between tardive dyskinesia and mortality over a 10-year period, using the National Death Index.

METHOD

Death certificates were obtained from the National Death Index on 1621 people repeatedly assessed for tardive dyskinesia by trained raters. Variables with the potential for influencing survival time were also investigated.

RESULTS

Tardive dyskinesia was significantly associated with an increase in mortality (P<0.001), but this association became non-significant when drug course and age were entered in the regression analysis. Those who had taken only conventional antipsychotics were twice as likely to die compared with those taking atypical agents (P<0.02). For those aged 53-65 years, conventional agents were associated with a sevenfold increase in mortality.

CONCLUSIONS

Older individuals with tardive dyskinesia treated with conventional antipsychotics appear to have a shortened survival time.

Mortality rates among patients with schizophrenia and tardive dyskinesia

Tardive dyskinesia (TD) is a severe and potentially irreversible movement, and previous studies have suggested increased mortality among patients with TD, but most of these studies are limited by small sample sizes and short periods of follow-up. This study examined the mortality rate of a cohort of 608 Asian patients with schizophrenia during a 6-year period and used survival analyses on time from case ascertainment to outcome (death). Data on the survival status were collected and compared between those with and without TD, and cross-tabulation was performed to show the correlation between survival and mortality rates among patients with and without TD.Seventy-two patients died, 39 (54.2%) of whom had TD previously. Of the 536 surviving cases, 239 (44.6%) have TD. The mortality rates between those with TD and those without TD were statistically significant (hazard ratio, 2.62; 95% confidence interval, 1.58-4.33; P = 0.0006).The mortality rate was dependent on age; nevertheless, the adverse effect of TD on survival rate, although reduced, remains after controlling for age (hazard ratio, 1.90; 95% confidence interval, 1.12-3.20; P = 0.017). Our finding showed a robust association with increased mortality rate and TD, but we failed to find any significant association with any specific cause of death and TD.

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.

Tardive Dyskinesia Risks and Metoclopramide Use Before and After U.S. Market Withdrawal of Cisapride

OBJECTIVE

To assess risk factors for tardive dyskinesia (TD) in spontaneous reports of metoclopramide and TD and evaluate metoclopramide prescribing patterns before and after withdrawal of cisapride from the market in the United States.

DESIGN

Retrospective and observational analyses.

SETTING

International metoclopramide adverse event reports and domestic drug-use data for the continental United States.

PATIENTS

Users of metoclopramide for 30 days or more who experienced adverse events reported as TD.

INTERVENTIONS

Analyses of the Food and Drug Administration Adverse Event Reporting System (AERS) and IMS HEALTH data.

MAIN OUTCOME MEASURES

Pharmacoepidemiological patterns in AERS reports and utilization data from IMS HEALTH.

RESULTS

The case series comprised 87 reports of primarily older (mean+/-SD, 60+/-22 years ) women (67% of all cases). While average metoclopramide daily dose (33+/-14 mg) was within recommended product labeling limits, duration of use was considerably longer (753+/-951 days). Overall, 37% of the reports included concomitant drugs believed to be TD risk factors. Similarly, 18% of the reports noted comorbid diseases that are considered risk factors for development of TD. Metoclopramide utilization decreased following cisapride marketing in 1993 and increased following cisapride withdrawal in 2000. The majority (62%) of metoclopramide prescriptions were intended for women. Intended use overall increased with age and was highest in the seventh and eighth decades, with nearly one quarter of all utilization being in persons older than 70 years.

CONCLUSION

Well-described TD risk factors were common in metoclopramide-associated TD reports. Given the cisapride market withdrawal and associated increased metoclopramide utilization, the incidence of TD may increase accordingly. TD risk factors relative to the intended benefit and duration of use should be considered in metoclopramide prescribing.

Olanzapine treatment for tardive dyskinesia in schizophrenia patients: a prospective clinical trial with patients randomized to blinded dose reduction periods

BACKGROUND

Tardive dyskinesia (TD) is a potentially persistent and disabling abnormal involuntary movement disorder. The aim of this 8-month study was to determine if olanzapine treatment could lead to a significant and persistent reduction in preexisting TD.

METHODS

Eligible schizophrenia patients met restricted Research Diagnosis criteria of TD requiring, in part, a rating of at least moderate severity (score > or = 3) in one or more of seven body regions on the Abnormal Involuntary Movement Scale (AIMS). Patients received olanzapine, 5-20 mg/day, for 8 months. During this period, they underwent one to two dose reduction periods under blinded conditions. Concurrent changes in TD, psychopathology, parkinsonism and akathisia were assessed with the AIMS, the Positive and Negative Syndrome Scale (PANSS), and the Simpson-Angus and Barnes Akathisia Scales, respectively.

RESULTS

A significant reduction in mean AIMS total score was demonstrated at endpoint (n = 92; p < 0.001) as well as at each visit (p < 0.001) and as early as Week 1 on olanzapine. Approximately 70% of patients no longer met the restricted Research Diagnostic criteria for persistent TD (RD-TD) after 8 months of treatment. No statistically significant rebound worsening of TD was found during either blinded drug reduction period. Significant improvement in psychopathology (p = 0.001) and parkinsonism (p < 0.001) was observed.

CONCLUSIONS

Improvement in the severity of preexisting TD was achieved with olanzapine and persisted throughout the 8-month study and during each dose reduction period. Overall improvement in clinical status suggests that olanzapine may be effective for the long-term management of schizophrenia patients with preexisting TD.

Eicosapentaenoic acid in the treatment of schizophrenia and depression: rationale and preliminary double-blind clinical trial results

It has been hypothesised that polyunsaturated fatty acids (PUFA) play an important role in the aetiology of schizophrenia and depression. Evidence supporting this hypothesis for schizophrenia includes abnormal brain phospholipid turnover shown by 31P Magnetic Resonance Spectroscopy, increased levels of phospholipase A2, reduced niacin skin flush response, abnormal electroretinogram, and reduced cell membrane levels of n-3 and n-6 PUFA. In depression, there is strong epidemiological evidence that fish consumption reduces risk of becoming depressed and evidence that cell membrane levels of n-3 PUFA are reduced. Four out of five placebo-controlled double- blind trials of eicosapentaenoic acid (EPA) in the treatment of schizophrenia have given positive findings. In depression, two placebo-controlled trials have shown a strong therapeutic effect of ethyl-EPA added to existing medication. The mode of action of EPA is currently not known, but recent evidence suggests that arachidonic acid (AA) if of particular importance in schizophrenia and that clinical improvement in schizophrenic patients using EPA treatment correlates with changes in AA.