Clinical nonrecognition of neuroleptic-induced movement disorders: a cautionary study

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.

Candidate Genes Encoding Dopamine Receptors as Predictors of the Risk of Antipsychotic-Induced Parkinsonism and Tardive Dyskinesia in Schizophrenic Patients

(1) Introduction: Extrapyramidal disorders form the so-called extrapyramidal syndrome (EPS), which is characterized by the occurrence of motor disorders as a result of damage to the basal ganglia and the subcortical-thalamic connections. Often, this syndrome develops while taking medications, in particular antipsychotics (APs). (2) Purpose: To review studies of candidate genes encoding dopamine receptors as genetic predictors of development of AP-induced parkinsonism (AIP) and AP-induced tardive dyskinesia (AITD) in patients with schizophrenia. (3) Materials and Methods: A search was carried out for publications of PubMed, Web of Science, Springer, and e-Library databases by keywords and their combinations over the last 10 years. In addition, the review includes earlier publications of historical interest. Despite extensive searches of these commonly used databases and search terms, it cannot be ruled out that some publications were possibly missed. (4) Results: The review considers candidate genes encoding dopamine receptors involved in pharmacodynamics, including genes DRD1, DRD2, DRD3, and DRD4. We analyzed 18 genome-wide studies examining 37 genetic variations, including single nucleotide variants (SNVs)/polymorphisms of four candidate genes involved in the development of AIP and AITD in patients with schizophrenia. Among such a set of obtained results, only 14 positive associations were revealed: rs1799732 (141CIns/Del), rs1800497 (C/T), rs6275 (C/T), rs6275 (C/T) DRD2; rs167771 (G/A) DRD3 with AIP and rs4532 (A/G) DRD1, rs6277 (C/T), rs6275 (C/T), rs1800497 (C/T), rs1079597 (A/G), rs1799732 (141CIns/Del), rs1045280 (C/G) DRD2, rs6280 (C/T), rs905568 (C/G) DRD3 with AITD. However, at present, it should be recognized that there is no final or unique decision on the leading role of any particular SNVs/polymorphisms in the development of AIP and AITD. (5) Conclusion: Disclosure of genetic predictors of the development of AIP and AITD, as the most common neurological adverse drug reactions (ADRs) in the treatment of patients with psychiatric disorders, may provide a key to the development of a strategy for personalized prevention and treatment of the considered complication of AP therapy for schizophrenia in real clinical practice.

Correlates of the Abnormal Involuntary Movement Scale in Veterans With Tardive Dyskinesia

PURPOSE/BACKGROUND

To add to limited evidence on the Abnormal Involuntary Movement Scale (AIMS) as a measure of tardive dyskinesia (TD) in clinical practice settings, the characteristics and correlates of AIMS scores were assessed.

METHODS/PROCEDURES

Veterans with schizophrenia/schizoaffective, bipolar, or major depressive disorders receiving antipsychotics and at least 1 AIMS score during October 1, 2014, to September 30, 2015, were identified. Tardive dyskinesia was determined by the International Classification of Diseases, Ninth Revision, Clinical Modification, codes. Correlates of AIMS scores were examined using χ or t tests. Odds ratios and β parameters with 95% confidence intervals for categorical and continuous variables associated with AIMS scores were derived from a multivariate logistic and linear regression, respectively.

FINDINGS/RESULTS

Among 7985 veterans receiving antipsychotics, only 4706 (58.9%) had at least 1 AIMS examination. Of these, 229 (4.9%) were diagnosed with possible TD. The mean total AIMS scores and AIMS awareness/incapacitation scores were significantly higher for patients with TD (both P < 0.0001). Comparing diagnostic threshold criteria of AIMS ratings, only 17.5% to 37.1% of veterans with TD were successfully identified. Among TD patients, 21.4% had a total score of moderate-severe and 15.3% had ratings of at least mild movements in 2 or more body regions. In the regression analyses, being older, African-American, having schizophrenia/schizoaffective disorder, and receiving antipsychotics or benztropine significantly increased the severity of AIMS scores. Higher AIMS scores were not predictive of outcomes other than marital status in socioeconomic or healthcare domains.

IMPLICATIONS/CONCLUSIONS

Although the AIMS is essential for TD research, its value in clinical practice without training and oversight remains unclear. Efforts to adapt screening procedures to clinical needs may be worthwhile.

Treatment of Antipsychotic-Induced Akathisia: Role of Serotonin 5-HT2a Receptor Antagonists

Akathisia is one of the most prevalent and distressing adverse effects associated with antipsychotic drug treatment. Propranolol, a non-selective beta-adrenergic receptor antagonist, is currently considered a first-line treatment for antipsychotic-induced akathisia (AIA). Surprisingly, the evidence for its anti-akathisia effect is modest. Propranolol's side effects (e.g. orthostatic hypotension, bradycardia), contraindications (e.g. asthma) and increased complexity in titration schedules limit its use in some patients. Anticholinergic agents and benzodiazepines merely provide symptomatic relief in patients with AIA. Effective and well-tolerated treatment remains a major unmet need in akathisia and warrants a search for new anti-akathisia agents. Accumulating evidence during the last two decades indicates that agents with marked postsynaptic serotonin 5-HT_2a receptor antagonism (ritanserin, cyproheptadine, trazodone, mianserin, mirtazapine) may represent a new class of potential anti-akathisia remedies. Among these agents, low-dose mirtazapine (7.5 mg or 15 mg once daily) has demonstrated the most compelling evidence for therapeutic efficacy. In this narrative review we highlight the clinical significance of AIA, outline major approaches for its management and propose a practical algorithm for its treatment.

Prophylactic Administration of Diphenhydramine to Reduce Neuroleptic Side Effects in the Acute Care Setting: A Systematic Review and Meta-Analysis

BACKGROUND

Neuroleptics are commonly prescribed drugs to treat acute conditions (e.g., migraines) in the emergency department, but can cause serious adverse effects. Using diphenhydramine to prevent these adverse effects is very common but remains controversial.

OBJECTIVE

We performed a systematic review to determine whether prophylactic administration of diphenhydramine reduces the incidence of neuroleptic adverse effects in patients with acute conditions.

METHODS

Medline, Embase, Cochrane, PsycInfo, and Web of Science were searched for randomized controlled trials evaluating any neuroleptic with diphenhydramine vs. the same neuroleptic with any inactive agent. Primary outcome was incidence of any extrapyramidal adverse effect. Secondary outcomes were akathisia, rescue medication, subjective restlessness, neuroleptic malignant syndrome, and sedation. Independent reviewers scanned identified citations, extracted data, and assessed risk of bias. Meta-analysis was performed using random effect models.

RESULTS

Of 1566 identified citations, nine studies (n = 1648 patients) met eligibility criteria. Four studies were specifically designed to compare the incidence of neuroleptic adverse effects with and without co-administration of diphenhydramine. Four studies were at high risk of bias. In primary analysis, diphenhydramine had no effect on the incidence of extrapyramidal symptoms (7 studies, n = 1393, risk ratio [RR] 0.75; 95% confidence interval [CI] 0.44-1.31) or akathisia (5 studies, n = 1094; RR 0.78; 95% CI 0.33-1.82) or any of the secondary outcomes. In subgroup analysis, diphenhydramine was associated with a significant decrease in extrapyramidal adverse effects compared with placebo (4 studies, n = 705; RR 0.61; 95% CI 0.41-0.90). Dosage analysis yielded no further information.

CONCLUSIONS

When compared with placebo, diphenhydramine was associated with a significant reduction of extrapyramidal adverse effects. Overall quality of evidence is low. Further studies are warranted.

Cumulative Burden of Illness in Veterans With Tardive Dyskinesia and Serious Mental Disorders

PURPOSE/BACKGROUND

To inform cost-benefit decisions for veterans, the risk of tardive dyskinesia (TD) and its impact on comorbidities and outcomes were assessed.

METHODS/PROCEDURES

In a retrospective study, veterans with schizophrenia/schizoaffective, and bipolar and major depressive disorders receiving antipsychotics during the period October 1, 2014, to September 30, 2015, were identified. Tardive dyskinesia was determined by International Classification of Diseases, Ninth Revision, Clinical Modification codes. Correlates of TD were examined using χ or t tests. Odds ratios (ORs) and β parameters with 95% confidence intervals (CIs) for categorical and continuous variables associated with TD were derived from a multivariate logistic and linear regression, respectively.

FINDINGS/RESULTS

Among 7985 veterans, 332 (4.2%) were diagnosed as having possible TD. The odds of having TD were higher for older veterans (OR, 1.04; 95% CI, 1.03-1.05; P < 0.0001) and veterans with schizophrenia/schizoaffective disorder (OR, 1.54; 95% CI, 1.23-1.91; P < 0.0001) or diabetes (OR, 1.64; 95% CI, 1.30-2.06; P < 0.0001). Veterans with TD received more antipsychotic prescriptions (mean ± SD, 18.4 ± 30.3 vs 13.3 ± 26.4; P = 0.003) and days of supply (233.9 ± 95.4 vs 211.4 ± 102.0; P < 0.0001). They were more likely to have received 2 or more antipsychotics (27.1% vs 19.7%, P = 0.0009) and benztropine (OR, 2.25: 95% CI 1.73-2.91; P < 0.0001). Veterans with TD had a higher Charlson Comorbidity Index score (β = 0.32; SE, 0.09; 95% CI, 0.14-0.49; P = 0.0003) and higher odds of any medical hospitalization (OR, 1.45; 95% CI, 1.07-1.95; P = 0.001).

IMPLICATIONS/CONCLUSIONS

The diagnosis of possible TD was associated with older age, schizophrenia/schizoaffective disorder, medical comorbidity, and hospitalization. Tardive dyskinesia may be a marker for patients at risk of adverse health care outcomes and diminished quality of life.

Tardive Syndromes

PURPOSE OF REVIEW

This article reviews the history, nosology, clinical features, epidemiology, and treatment of tardive syndromes.

RECENT FINDINGS

The major advance in the field of tardive syndromes has been the development and US Food and Drug Administration (FDA) approval of two vesicular monoamine transporter type 2 inhibitors, valbenazine and deutetrabenazine, for treating tardive syndromes. These medications are derivatives of tetrabenazine and reduce dyskinetic movements by reducing dopamine stimulation. Treatment is not curative, and the medications reduce, or "mask," symptoms but presumably without adding to the long-term risk of increased involuntary movements believed to accrue from suppressive treatment with dopamine receptor-blocking drugs. A confounding advance has been the accumulation of data finding that second-generation antipsychotics, also known as atypical antipsychotics, may not be safer than first-generation antipsychotics in causing tardive syndromes. The public health risk of tardive syndromes may actually have increased as some second-generation antipsychotics, widely promoted to both doctors and patients, are increasingly used as antidepressants.

SUMMARY

Tardive syndromes remain a public health risk. Second-generation antipsychotics have not been proven to have less risk than first-generation drugs in causing tardive syndromes and are nevertheless being used more widely to treat depression, bipolar disease, and insomnia. Symptomatic treatment for tardive syndromes is available, although expensive.

The nature of bradykinesia in schizophrenia treated with antipsychotics

Recognizing drug-induced parkinsonian bradykinesia in psychosis patients can be challenging due to overlapping presentation with psychomotor slowing associated with depression, negative symptoms, or cognitive disturbances. In this study, we apply prior findings on the pathophysiology of bradykinesia in Parkinson's disease to gain an understanding of motor slowing in psychosis patients. Handwriting movements from 57 healthy participants and 70 psychosis patients were recorded on a digitizing tablet. Temporal and kinematic features were extracted from handwritten loops and circles. An independent objective measure based on peak velocity for circles written at maximum speed was used to classify patients as bradykinetic. Using a statistical cut-point derived from normative data, 64% of the patients met criterion for bradykinesia compared with 46% using a conventional observer-based severity rating scale. Bradykinetic patients produced handwriting movements with longer stroke durations, smaller amplitudes and lower peak velocities compared with non-bradykinetic patients. Thirty-six percent of the pen strokes produced by the bradykinetic patients were non-ballistic compare with 20% for the non-bradykinetic patients. The proportion of nonballistic movements observed in handwriting was unrelated to current antipsychotic dose, severity of negative psychosis or depression. The ease-of-use and standardization of a tablet-based approach to quantifying parkinsonian bradykinesia can aid in diagnosing parkinsonian bradykinesia in patients treated with antipsychotics.

The Assessment and Treatment of Antipsychotic-Induced Akathisia

BACKGROUND

Akathisia is a common and distressing neuropsychiatric syndrome associated with antipsychotic medication, characterised by subjective and objective psychomotor restlessness. The goal of this guideline is to provide clinicians with recommendations on the assessment and treatment of akathisia.

METHODS

We performed a systematic review of therapeutic studies assessing the treatment of antipsychotic-induced extrapyramidal symptoms. Forty studies on akathisia and 4 systematic reviews evaluating the adverse effects of antipsychotics were used in the formulation of recommendations. Studies were rated for methodological quality using the American Academy of Neurology Risk of Bias Classification system. The overall level of evidence classifications and grades of recommendation were made using the Scottish Intercollegiate Guidelines Network framework.

RESULTS

As a good practice point, clinicians should systematically assess akathisia with a validated scale before starting antipsychotics and during antipsychotic dosage titration. For the management of akathisia, there was adequate evidence to allow recommendations regarding antipsychotic dose reduction, antipsychotic polypharmacy, switching antipsychotic medication, and the use of adjuvant medications including beta-blockers, anticholinergics, 5HT_2A antagonists, benzodiazepines, and vitamin B6.

CONCLUSION

The treatment of antipsychotic-induced akathisia should be personalised, with consideration of antipsychotic dose reduction, cessation of antipsychotic polypharmacy, and switching to an antipsychotic with a perceived lower liability for akathisia, before the use of adjuvant medications. The choice of adjuvant medications should favour the more established treatments, with careful consideration of contraindications and side effects. Limitations in the evidence should be acknowledged and prompt cautious prescribing, particularly with respect to the duration of use of adjuvant medications, is warranted.

Antipsychotic-Related Movement Disorders: Drug-Induced Parkinsonism vs. Tardive Dyskinesia-Key Differences in Pathophysiology and Clinical Management

Introduction

Drug-induced parkinsonism (DIP) and tardive dyskinesia (TD) are stigmatizing movement disorders associated with exposure to dopamine receptor blocking agents such as antipsychotics, but they differ in their pathophysiology and clinical management. Treatment for one may worsen the other, and there are important diagnostic clues that assist in making an accurate assessment and instituting a rational treatment plan.

Methods

A literature review was executed to identify articles relating to the presentation, pathophysiology, epidemiology, and management of DIP and TD.

Results

DIP and TD prevalence estimates range from approximately 20 to 35% among antipsychotic users, but may be higher in select populations. DIP often presents as bradykinesia and rigidity, as well as rhythmic tremor, and the majority of cases appear within hours to weeks of initiation of therapy with an antipsychotic, or if dosage of the antipsychotic is increased. TD onset is delayed, typically appearing after at least 3 months or longer of treatment, and patients will commonly present with involuntary, abnormal facial movements such as lip smacking, puckering, chewing, or tongue protrusion. DIP often resolves with discontinuation of the causative agent, but TD may be permanent. Broadly, proposed mechanisms underlying these adverse events include decreased dopamine concentrations in the nigrostriatal pathway of the striatum and dopamine hypersensitivity, for DIP and TD, respectively. Pharmacologic treatment approaches for DIP have commonly included anticholinergic agents such as benztropine; however, anticholinergic medications can make TD worse. Switching the antipsychotic medication to one with lower propensity for DIP is an option for some patients. Amantadine, a non-anticholinergic agent used for the treatment of DIP, may be preferred in patients with comorbid DIP and TD. In TD, treatment options include the new reversible vesicular monoamine 2 transporter inhibitors, valbenazine and deutetrabenazine.

Conclusions

It is important for clinicians to be able to recognize DIP and TD in patients using antipsychotics so that they can minimize the impact of these adverse events on their patients’ quality of life. Accurate diagnosis will drive the selection of the correct treatment.

Plain Language Summary

Plain language summary available for this article.

Parkinsonism in a population-based study of individuals aged 75+ years: The Pietà study

INTRODUCTION

Parkinsonism is one of the most prevalent neurological syndromes in the elderly. There are only a few epidemiological studies focusing on parkinsonism in oldest-old individuals, particularly in Latin America. This study aims to investigate the prevalence and characteristics of parkinsonism in subjects aged 75 + years living in the community.

METHODS

The Pietà study is a population-based investigation on brain aging conducted in Caeté, southeast Brazil. A sample composed of 610 community-dwelling individuals aged 75 + years (48.7% of the total population within this age range) underwent clinical, neurological, cognitive and functional assessments.

RESULTS

The sample comprised mostly women (61.5%), with mean age of 83.3 years and mean schooling of 2.5 years. Parkinsonism was identified in 65 subjects (crude prevalence = 10.7%). Parkinson's disease, Parkinsonism + dementia syndrome, drug-induced parkinsonism, vascular parkinsonism and Lewy-body dementia were identified in, respectively, 19 (29.2%), 19 (29.2%), 8 (12.3%), 4 (6.1%) and 1 (1.5%) subjects. In 14 individuals (21.5%), the etiology of parkinsonism could not be determined. The most important vascular risk factor was hypertension (64.6%). Cognitive evaluation disclosed dementia in 37 (56.9%) subjects. Mean Pfeffer's functional activities questionnaire score was 12.2 points and 22 (33.8%) subjects were impaired in basic activities of daily living.

CONCLUSION

Parkinsonism was common in this oldest-old population, being associated with dementia and vascular risk factors, particularly hypertension. Different confounders, such as concomitant dementia and exposure to anti-dopaminergic drugs, were present in this population, challenging the definition of causes of parkinsonism.

How CATIE brought us back to Kansas: a critical re-evaluation of the concept of atypical antipsychotics and their place in the treatment of schizophrenia

The subdivision of the class of antipsychotic drugs into two discrete groups – ‘conventional’ (or first generation) and ‘atypical’ (or second generation) – has been adopted as standard, with the latter generally accepted as ‘better’ and widely recommended as automatic first-line choices. However, this perception has been thrown into confusion with the results of large pragmatic trials that failed to identify advantages with the new, more expensive drugs, while identifying worrying tolerability issues. This article explores the origins of ‘atypicality’, its construction on the back of a confusing and weak clinical validator (diminished liability to promote parkinsonism) and how even in relation to the archetypical atypical, clozapine, the uncertain boundaries of drug-induced extrapyramidal dysfunction may be contributing to confusion about ‘efficacy’ and ‘tolerability’. It argues that abandoning atypicality would open up clinical practice to all drugs of a single class of ‘antipsychotics’ and allow for individualised risk/benefit appraisal as a basis for truly tailored treatment recommendations.

Early detection of antipsychotic side-effects

Aims and methods

Staff from five community mental health teams (CMHTs) were trained to use structured rating scales for akathisia, tardive dyskinesia and Parkinsonism. Detection rates of these side-effects were compared for the six months before and after the intervention.

Results

Fifty-seven per cent of the target professionals participated, screening 200 (52%) eligible patients. This resulted in significant increases in the recording of all three side-effects as positive but no increase in their formal diagnosis.

Clinical implications

Detection rates of these side-effects can be increased to those predicted by research with significant reductions in drug dose and non-adherence and without clinical deterioration.

Monitoring of extrapyramidal side effects in patients on antipsychotic treatment: a completed audit cycle

BACKGROUND

Movement disorders are a common problem in those receiving antipsychotic medication. Clinical guidelines recommend that these side-effects are monitored regularly throughout treatment. However, due to a lack of training, clinician confidence levels in assessment are often low and regular monitoring may be neglected. Aims To audit current practice in our services regarding monitoring of extrapyramidal side effects (EPSE) and improve monitoring through education of clinicians.

METHOD

The clinical records of patients receiving antipsychotic treatment, seen in the outpatient clinic over a 2-week period, were reviewed. Data were collected on whether or not EPSE had been assessed. A re-audit was undertaken following a teaching session.

RESULTS

Documentation regarding EPSE was present in only 14% of patient records. Following a teaching session, the overall level of documentation of EPSE rose to 42%, with rates of assessment dramatically improving in non-consultant hospital doctors.

CONCLUSION

In our practice, clinicians are generally poor to assess and record EPSE. However, rates of assessment improved significantly following a teaching session, especially in NCHDs.

Comparing the risk of tardive dyskinesia in older adults with first-generation and second-generation antipsychotics: a systematic review and meta-analysis

OBJECTIVE

The advent of second-generation antipsychotics (SGAs) in the 1990s brought optimism that neuroleptic-induced tardive dyskinesia (TD) may become relegated to history. Whether or not this is the case remains inconclusive, and this review aims to compare the risk of TD in older adults treated with first-generation antipsychotics (FGAs) versus SGAs.

METHODS

Relevant papers were sourced via a range of electronic databases, with a date range from 1957 to January 2015. Included studies used both a validated rating scale and research diagnostic criteria to report on the prevalence or incidence of TD in older adults exposed to antipsychotic medications.

RESULTS

For FGAs, the prevalence estimate was 53% (95% confidence interval [CI] [39.0, 68.4]) for mild TD and 38% (95% CI [25.9, 50.3]) for probable TD. Incidence estimates for probable TD with FGAs were 23% (95% CI [15.3, 30.6]) at 1 year, 42% (95% CI [24.8, 58.4]) at 2 years and 57% (95% CI [45.3, 69.1]) at 3 years. For SGAs, the incidence estimates at 1 year were 7% (95% CI [4.4, 10.2]) for probable TD and 3% (95% CI [1.5, 4.2]) for persistent TD.

CONCLUSIONS

The risk of probable TD is more than three times lower in older adults receiving SGAs in comparison with FGAs after 1 year of treatment (23% vs 7%). The risk of persistent TD at 1 year with SGAs is particularly low. Evidence is lacking in regard to the longer-term risk of TD with SGAs, although the rates associated with the prolonged use of FGAs are high. Caution is therefore still required, particularly with the protracted use of both FGAs and SGAs.

Dyskinesia in chronic schizophrenia: an examination of the psychiatric nurse's perspective and its implications for physiotherapy

The emerging biological explanation for dyskinesia in schizophrenia may allow physiotherapists to become involved in their treatment. However, this could be influenced by the views of psychiatric nurses who are major referers to physiotherapy. The aim of this study was to explore nurses' views on the aetiology and management of dyskinesia in schizophrenia. Four out of six nurses (randomly selected from a population of 83) took part in an unstructured group interview. Content analysis of transcripts identified five abnormal movement categories (oro-facial, posture, hand tremors, gait, and head, trunk and limbs) and five aetiological symbols (drugs, abnormal mental state, eclectic, mood, and behaviour). Contingency analysis revealed that drugs were the most consistent aetiological factor in all movement categories. Organic causes were not mentioned. An acknowledgement of these biological explanations by nursing staff may enhance the future development of physiotherapy intervention in mental illness.

Drug-Induced Movement Disorders

Drug-induced movement disorders (DIMDs) pose a significant burden to patients, often resulting in nonadherence, disease relapse, and decreased quality of life. Dopamine-receptor blocking agents such as conventional antipsychotics (eg, haloperidol and chlorpromazine) and antiemetics (eg, metoclopramide and prochlorperazine) are most commonly implicated. DIMDs can be categorized by the onset of symptoms: acute reactions occurring hours to days after exposure, subacute DIMDs appearing within weeks, and tardive occurring months to years after drug exposure. The DIMDs of akathisia, tardive dyskinesia, dystonia, and parkinsonism are reviewed. Their epidemiology, mechanism, clinical presentation and differential diagnosis, risk factors, morbidity and mortality, and prevention and management are discussed. For many of these disorders, treatment inconsistently provides benefit, and therefore, primary prevention is essential. Clinicians and other healthcare professionals play a key role in the identification of patients with DIMDs, or those at risk, and in implementing prevention and treatment plans.

Psychoactive Drug Misuse in Long-Term Care: Some Contributing Factors

Surveys have identified inappropriate psychoactive drug prescribing patterns as a major problem in the care of nursing home residents. Residents without a documented history of mental illness often receive drugs intended to treat psychiatric problems. One of the greatest areas of misuse of these drugs is in the treatment of agitation in elderly demented residents. For example, although this purpose is likely the most common reason antipsychotic drugs are used in the nursing home setting, no well designed study has yet demonstrated that these agents are effective for this problem. Elderly individuals are particularly sensitive to the adverse effects of psychoactive drugs. Due to the gradual or insidious onset of some adverse effects, psychoactive drug toxicity may often be underestimated. The most serious example of a clinically underrecognized adverse effect of psychoactive drugs is tardive dyskinesia. Misinterpretation of certain nursing home residents' behaviors may lead to medication with tranquilizing drugs when other approaches may be safer and more effective. Excessive use of psychoactive drugs is not only physically harmful, but also encourages an apathetic attitude toward implementation of more humane ways of dealing with behaviorally disturbed nursing home residents.

A Randomized Trial of Iloperidone for Prevention of Relapse in Schizophrenia: The REPRIEVE Study

BACKGROUND

The purpose of this study was to evaluate the safety and effectiveness of iloperidone for the prevention of relapse in schizophrenia.

METHODS

Study subjects were adults with schizophrenia who started on oral open-label iloperidone titrated to an initial target dose of 12 mg/day (6 mg twice daily) and then stabilized on a flexible-dose iloperidone regimen (range 8-24 mg/day) for up to 24 weeks. Subjects meeting stabilization criteria then entered the relapse-prevention phase and were randomized 1:1 in a double-blind fashion to continue with iloperidone or placebo withdrawal for up to 26 weeks or until meeting relapse or other withdrawal criteria.

RESULTS

A total of 303 subjects were randomized to the relapse-prevention phase; 153 continued to receive iloperidone, and 150 were withdrawn to placebo. The modal total daily dose for iloperidone in all phases of the study was 12 mg/day. The pre-defined unblinded interim analysis upon reaching 68 relapse events confirmed the hypothesis that iloperidone (n = 97) was more effective than placebo (n = 96) in preventing relapse events, and the trial was stopped early. The estimated relapse rates were 63.4 % (Kaplan-Meier [KM] estimate) for placebo compared with 20.4 % (KM estimate) for those continuing to receive iloperidone (log rank test: p < 0.0001). The mean time to relapse was 71 days for placebo and 139 days for iloperidone (hazard ratio 4.7; 95 % confidence interval 2.7-8.3; p < 0.0001). The safety profile observed in previous short-term studies was also reaffirmed in this maintenance treatment setting. The most common treatment-emergent adverse events (TEAEs) in the stabilization phase were dizziness (11.6 %), somnolence (8.3 %), and dry mouth (6.8 %). Rates of reported extrapyramidal disorder or akathisia during stabilization were 2.5 and 3.7 %, respectively.

CONCLUSIONS

Flexible dosing of iloperidone for maintenance-phase therapy, with a modal dose of 12 mg/day was effective in preventing relapse in subjects previously stabilized on iloperidone. The adverse event profile for iloperidone was consistent with other studies, and the low extrapyramidal symptom and akathisia burden during stabilization was sustained during the course of the study. ClinicalTrials.gov identifier: NCT01291511.

The clinical challenges of akathisia

Akathisia is one of the most vexing problems in neuropsychiatry. Although it is one of the most common side effects of antipsychotic medications, it is often difficult to describe by patients, and is difficult to diagnose and treat by practitioners. Akathisia is usually grouped with extrapyramidal movement disorders (ie, movement disorders that originate outside the pyramidal or corticospinal tracts and generally involve the basal ganglia). Yet, it can present as a purely subjective clinical complaint, without overt movement abnormalities. It has been subtyped into acute, subacute, chronic, tardive, withdrawal-related, and "pseudo" forms, although the distinction between many of these is unclear. It is therefore not surprising that akathisia is generally either underdiagnosed or misdiagnosed, which is a serious problem because it can lead to such adverse outcomes as poor adherence to medications, exacerbation of psychiatric symptoms, and, in some cases, aggression, violence, and suicide. In this article, we will attempt to address some of the confusion surrounding the condition, its relationship to other disorders, and differential diagnosis, as well as treatment alternatives.

Viewpoint: challenges in our understanding of neuroleptic induced parkinsonism

Parkinsonism remains a common and often overlooked adverse effect of almost all neuroleptic drugs, including the "atypical," or "second generation" antipsychotics. While neuroleptic induced parkinsonism (NIP) is often thought to be well understood in terms of its clinical course, pathophysiology, and treatment, this is clearly not the case, and almost all our current beliefs are based on data published decades ago of dubious merit, and recent studies which are confounded by design conflicts. This article attempts to highlight gaps in our knowledge. While there are data on the stigma associated with idiopathic Parkinson's disease, there are none on NIP, where the problem is most likely much greater. The natural course of NIP remains unknown, including the question of whether this is a risk factor for the later development of tardive dyskinesia. While treatment with anticholinergics or amantadine is the norm, there are weak and conflicting data on whether these have much value. Why quetiapine and clozapine do not worsen motor function in people with idiopathic PD, while all other neuroleptic do, remains uncertain. Neuroleptics are among the most widely prescribed medications in the United States, with 20% of nursing home residents taking them, with an increasing use for treating depression as well as psychosis, underscoring the importance of understanding NIP, the most important adverse motor effect of this class of drugs.

Treating an established episode of delirium in palliative care: expert opinion and review of the current evidence base with recommendations for future development

CONTEXT

Delirium is a highly prevalent complication in patients in palliative care settings, especially in the end-of-life context.

OBJECTIVES

To review the current evidence base for treating episodes of delirium in palliative care settings and propose a framework for future development.

METHODS

We combined multidisciplinary input from delirium researchers and other purposely selected stakeholders at an international delirium study planning meeting. This was supplemented by a literature search of multiple databases and relevant reference lists to identify studies regarding therapeutic interventions for delirium.

RESULTS

The context of delirium management in palliative care is highly variable. The standard management of a delirium episode includes the investigation of precipitating and aggravating factors followed by symptomatic treatment with drug therapy. However, the intensity of this management depends on illness trajectory and goals of care in addition to the local availability of both investigative modalities and therapeutic interventions. Pharmacologically, haloperidol remains the practice standard by consensus for symptomatic control. Dosing schedules are derived from expert opinion and various clinical practice guidelines as evidence-based data from palliative care settings are limited. The commonly used pharmacologic interventions for delirium in this population warrant evaluation in clinical trials to examine dosing and titration regimens, different routes of administration, and safety and efficacy compared with placebo.

CONCLUSION

Delirium treatment is multidimensional and includes the identification of precipitating and aggravating factors. For symptomatic management, haloperidol remains the practice standard. Further high-quality collaborative research investigating the appropriate treatment of this complex syndrome is needed.

5-HT2A receptor antagonists for the treatment of neuroleptic-induced akathisia: a systematic review and meta-analysis

Akathisia is a common and distressing extrapyramidal side-effect, which usually results from the use of antipsychotic medication. Previous reviews and meta-analyses have demonstrated a lack of evidence for the effectiveness of treatment strategies, which are traditionally used against neuroleptic-induced akathisia (NIA), i.e. beta-blockers, anticholinergic agents and benzodiazepines. In the last fifteen years, randomized trials have studied the effect of drugs with antiserotonergic properties on NIA. We conducted a systematic review of randomized control trials and used meta-analytic methods to quantify the overall effect size. PubMed and the Cochrane libraries were searched for eligible trials. Six randomized controlled trials were found, five of which included a placebo control group and qualified for our meta-analysis. The overall effect size in the analysis is RR = 7.10 with 95% CI 3.08-16.40 (p < 0.0001). Our findings suggest that 5-HT(2A) antagonists are effective in the treatment of NIA.

Commonly used gastrointestinal drugs

This chapter reviews the spectrum and mechanisms of neurologic adverse effects of commonly used gastrointestinal drugs including antiemetics, promotility drugs, laxatives, antimotility drugs, and drugs for acid-related disorders. The commonly used gastrointestinal drugs as a group are considered safe and are widely used. A range of neurologic complications are reported following use of various gastrointestinal drugs. Acute neurotoxicities, including transient akathisias, oculogyric crisis, delirium, seizures, and strokes, can develop after use of certain gastrointestinal medications, while disabling and pervasive tardive syndromes are described following long-term and often unsupervised use of phenothiazines, metoclopramide, and other drugs. In rare instances, some of the antiemetics can precipitate life-threatening extrapyramidal reactions, neuroleptic malignant syndrome, or serotonin syndrome. In contrast, concerns about the cardiovascular toxicity of drugs such as cisapride and tegaserod have been grave enough to lead to their withdrawal from many world markets. Awareness and recognition of the neurotoxicity of gastrointestinal drugs is essential to help weigh the benefit of their use against possible adverse effects, even if uncommon. Furthermore, as far as possible, drugs such as metoclopramide and others that can lead to tardive dyskinesias should be used for as short time as possible, with close clinical monitoring and patient education.

Non-adherence to medication in patients with psychotic disorders: epidemiology, contributing factors and management strategies

Although non-adherence is common across all branches of medicine, psychotic disorders pose additional challenges that increase its risk. Despite the importance of non-adherence, clinicians generally spend too little time on assessing and addressing adherence attitudes and behaviors. Importantly, how adherence is measured significantly impacts the findings, and the most frequently employed methods of asking patients or judging adherence indirectly based on efficacy or tolerability information have poor validity. Novel technologies are being developed that directly assess adherence and that can also be used to both provide real-time feedback to clinicians and serve as an intervention with patients. Several treatments are available that can positively impact adherence. Among psychosocial interventions, those combining multiple approaches and involving multiple domains seem to be most effective. Although long-acting injectable antipsychotics are theoretically a very powerful tool to assure adherence and signal non-adherence, recent results from randomized controlled trials failed to show superiority compared to oral antipsychotics. These data are in contrast to nationwide cohort studies and mirror-image studies, which arguably include more representative patients receiving long-acting antipsychotics in clinical practice. This disconnect suggests that traditional randomized controlled trials are not necessarily the best way to study interventions that are thought to work via reducing non-adherence. Clearly, non-adherence is likely to remain a major public health problem despite treatment advances. However, increasing knowledge about factors affecting adherence and leveraging novel technologies can enhance its early assessment and adequate management, particularly in patients with psychotic disorders.

World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of schizophrenia, part 2: update 2012 on the long-term treatment of schizophrenia and management of antipsychotic-induced side effects

Abstract These updated guidelines are based on a first edition of the World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of schizophrenia published in 2006. For this 2012 revision, all available publications pertaining to the biological treatment of schizophrenia were reviewed systematically to allow for an evidence-based update. These guidelines provide evidence-based practice recommendations that are clinically and scientifically meaningful. They are intended to be used by all physicians diagnosing and treating people suffering from schizophrenia. Based on the first version of these guidelines, a systematic review of the MEDLINE/PUBMED database and the Cochrane Library, in addition to data extraction from national treatment guidelines, has been performed for this update. The identified literature was evaluated with respect to the strength of evidence for its efficacy and then categorised into six levels of evidence (A-F) and five levels of recommendation (1-5) ( Bandelow et al. 2008a ,b, World J Biol Psychiatry 9:242, see Table 1 ). This second part of the updated guidelines covers long-term treatment as well as the management of relevant side effects. These guidelines are primarily concerned with the biological treatment (including antipsychotic medication and other pharmacological treatment options) of adults suffering from schizophrenia.

Antipsychotic drugs and extrapyramidal side effects in first episode psychosis: a systematic review of head-head comparisons

This systematic review aimed to determine whether the risk of extrapyramidal side effects (EPS) differed between antipsychotic drugs used in first episode psychosis (FEP). We identified 11 RCTs comparing two or more antipsychotics in FEP and reporting on EPS. All trials assessed one or more second generation antipsychotics (SGAs), one assessed chlorpromazine, one zuclopenthixol and seven trials assessed haloperidol. Assessment and reporting of EPS varied. Compared with one or more SGA comparators, haloperidol was associated with significantly higher rates/severity of parkinsonism (seven trials) and akathisia (six trials) and greater use of anticholinergics (five trials) and beta-blockers (two trials). Two trials with low-dose haloperidol (≤ 4 mg) showed significantly worse EPS outcomes versus a SGA. Two of four long-term haloperidol trials (≥ 1 year) found a higher dyskinesia-risk with haloperidol versus olanzapine and risperidone respectively; the remaining two trials found no difference (various SGA comparators). There was an EPS advantage for clozapine versus chlorpromazine (one trial) and risperidone versus zuclopenthixol (one trial). There was little evidence of EPS-differences between SGAs, possibly reflecting use of low doses. We conclude that SGAs offer an EPS advantage over FGAs in FEP though the evidence largely relates to comparisons with haloperidol. Standardized assessment and reporting of EPS would assist future research.

Applied monitoring for tardive dyskinesia and other extrapyramidal side effects

While the rate of tardive dyskinesia (TD) and other extrapyramidal side effects (EPSE) is lower with second generation antipsychotic medications compared to first generation antipsychotic medications, these side effects remain of clinical concern. This paper reviews the basis for the continued concern and the importance of secondary prevention, or early detection, within the primary-secondary-tertiary prevention model. The importance of standardized assessment instruments, education, and training is reviewed. Given the widespread use of antipsychotic drugs, the fact that antipsychotic drugs are the standard of care for several psychiatric conditions (with little indication that the magic bullet is on the immediate horizon to replace current antipsychotic drugs) applied monitoring and the early detection of TD and EPSE takes on added importance.

Are extrapyramidal symptoms less recognized? Case report of modern practitioners' unfamiliarity with first generation antipsychotics

A case is presented where initial suspicion of lithium toxicity was mistaken. Drug-induced Parkinsonism and tardive dyskinesia were present, underscoring the need to improve training of movement disorder assessment.

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.

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.

Incidence of tardive dyskinesia with atypical versus conventional antipsychotic medications: a prospective cohort study

OBJECTIVE

Most previous studies of the incidence of tardive dyskinesia with atypical antipsychotics compared with conventional antipsychotics have not had tardive dyskinesia as their primary focus. The current study aimed to compare the incidence of tardive dyskinesia with atypical vs conventional antipsychotics using methods similar to those from a previous prospective cohort study at our site in the 1980s.

METHOD

Three hundred fifty-two initially tardive dyskinesia-free psychiatric outpatients (diagnosed at baseline using the Structured Clinical Interview for DSM-IV) were examined for a new diagnosis of tardive dyskinesia (using the Abnormal Involuntary Movement Scale and Glazer-Morgenstern criteria) every 6 months for up to 4 years at a community mental health center. At baseline, subjects were receiving conventional antipsychotics only (23%), atypicals only (64%), or both (14%). Only 26 subjects had never received conventional antipsychotics. Baseline evaluations were conducted from November 2000 through May 2003. Follow-ups were conducted through February 2005.

RESULTS

Compared with subjects treated with conventional antipsychotics alone since the previous visit, the adjusted tardive dyskinesia incidence rate-ratio for subjects treated with atypical antipsychotics alone was 0.68 (95% CI, 0.29-1.64). The incidence and prevalence of tardive dyskinesia was similar to previous findings at this site in the 1980s.

CONCLUSIONS

The incidence of tardive dyskinesia with recent exposure to atypical antipsychotics alone was more similar to that for conventional antipsychotics than in most previous studies. Despite high penetration of atypical antipsychotics into clinical practice, the incidence and prevalence of tardive dyskinesia appeared relatively unchanged since the 1980s. Clinicians should continue to monitor for tardive dyskinesia, and researchers should continue to pursue efforts to treat or prevent it.

Drug-Induced Movement Disorders in Older Adults: An Overview for Clinical Practitioners

OBJECTIVE

To provide an overview of some of the most common drug-induced movement disorders (DIMD) seen in the elderly by the primary care clinician. The epidemiology, clinical presentation, differential diagnosis, treatment, risk factors, and preventive measures are presented for each DIMD.

DATA SOURCES

Medical literature and research article search utilizing PubMed (National Library of Medicine), Psych INFO (American Psychological Association), CINAHL Database (CINAHL Information Systems), the Library of Congress Catalogue, and the Internet.

STUDY SELECTION

Reviews and articles from 1954 to 2005 concerning various movement disorders associated with medication in older adults. DATA EXTRACTIONS: Data on movement disorders associated with medications ranging from possible or controversial to well-established.

DATA SYNTHESIS

With the aging of populations in the United States and other countries, the use of medications with potential risk of precipitating movement disorders is increasing. The majority of these iatrogenic problems will be first seen in the geriatric patient in various clinical settings, typically in a primary care setting. To a large extent they will be observed in patients with mild cognitive impairment or dementia having impaired recall and reduced capacity to participate in the diagnostic interview. The challenge to clinicians is complicated by the sizable number of medications that may be involved.

Validity and reliability of the Simpson-Angus Scale (SAS) in drug induced parkinsonism in the elderly

BACKGROUND

Quantification of drug induced parkinsonism (DIP) for study purposes is difficult. The most often used Simpson Angus Scale (SAS) lacks proper clinimetric evaluation. The newer Schedule for Assessment of Drug-Induced Movement Disorders (SADIMoD) shows good clinimetric characteristics, but has not been used in published clinical studies, probably due to the complexity of the scale.

OBJECTIVES

To evaluate internal consistency and inter-rater reliability of the SAS and the correlation ot f the SAS with the parkinsonism subscale of the SADIMoD in elderly.

METHOD

Fifteen elderly diagnosed with DIP were recruited. The patients were assessed three times with the SAS by three independent investigators. The resident also performed the SADIMoD. Internal consistency was measured by Cronbach's alpha-coefficient, inter-rater variability was examined with weighted kappa values and percentage of agreement and correlation to SADIMoD by Spearman's correlation coefficient.

RESULTS

SAS demonstrated good internal consistency reliability (Cronbach's alpha coefficients 0.83). Inter-rater reliability for sum score was good. For individual items slight agreement on the item salivation and moderate to very good agreement on remaining items calculated by weighted kappa values was reached. We found 87-100% agreement on the individual items with acceptance of 1 point difference between raters. The SAS demonstrated acceptable correlation with the SADIMoD parkinsonism subscale scores (Spearman's rho = 0.66; p < 0.01).

CONCLUSION

The SAS appears to be a valid and by different instructed health care professionals easy to perform research tool to evaluate DIP.

Failure of recognition of drug-induced parkinsonism in the elderly

Our objective was to evaluate the ability of neurologists to recognize and diagnose drug-induced Parkinsonism (DIP) in the elderly. DIP is a diagnostic challenge because it can be indistinguishable from Parkinson's disease, especially in the elderly. It is frequently under-recognized by psychiatrists and primary care physicians. Atypical antipsychotics (AA) are advertised for their low propensity to cause DIP. This may add to problems with recognition. We performed a retrospective record review of consecutive new parkinsonian patients seen over 2 years in a movement disorders clinic to examine the frequency, causative agents, and diagnostic accuracy of DIP by physicians, particularly neurologists. Of 354 Parkinsonian patients evaluated, 24 (6.8%) had DIP, 46% of these were due to AA and 29% were caused by metoclopramide. Of the 24 patients with DIP, only one was previously diagnosed accurately according to records. Nineteen patients (79%) were previously evaluated by a neurologist, and none of them was diagnosed with DIP. The primary reason for failure to recognize DIP relates to under-recognition of AA as possible cause. A majority remained on the inciting agents while dopaminergic drugs were prescribed. DIP was reversible when the inciting drug was stopped. DIP is a common form of parkinsonism and is under-recognized, even by neurologists. AA and metoclopramide do not appear to be well-known to cause DIP. Cessation of the offending agent results in improvement of symptoms and would eliminate the need for dopaminergic agents, which are known to commonly cause side effects in the elderly.

Neurological complications of psychiatric drugs: clinical features and management

This paper reviews the main neurological complications of psychiatric drugs, in particular antipsychotics and antidepressants. Extrapyramidal syndromes include acute dystonia, parkinsonism, akathisia, tardive dyskinesia and tardive dystonia. Extrapyramidal symptoms (EPS) are less frequent with atypical than with conventional antipsychotics but remain common in clinical practice partly due to lack of screening by health professionals. Neuroleptic malignant syndrome (NMS) consists of severe muscle rigidity, pyrexia, change in conscious level and autonomic disturbance but partial forms also occur. NMS is particularly associated with the initiation and rapid increase in dose of high-potency antipsychotics but it has been reported with all the atypical antipsychotics and rarely with other drugs including antidepressants. Serotonin toxicity comprises altered mental state (agitation, excitement, confusion), neuromuscular hyperactivity (tremor, clonus, myoclonus, hyper-reflexia) and autonomic hyperactivity and occurs on a spectrum. Severe cases, termed serotonin syndrome, usually follow the co-prescription of drugs that increase serotonergic transmission by different pathways, for example a monoamine oxidase inhibitor (MAOI) and a selective serotonin reuptake inhibitor (SSRI). Most antipsychotics and antidepressants lower the seizure threshold and can cause seizures; the risk is greater with clozapine than with other atypical antipsychotics and greater with tricyclic antidepressants (TCAs) than with SSRIs. In randomised controlled trials in elderly patients with dementia atypical antipsychotics are associated with a higher risk of stroke and death than placebo. Cohort studies suggest that conventional drugs carry at least the same risk. Cessation of treatment with antipsychotics and antidepressants can lead to a wide range of discontinuation symptoms which include movement disorders and other neurological symptoms. Clinicians need to be familiar with strategies to reduce the risk of these adverse events and to manage them when they arise. Their occurrence needs to be balanced against the benefits of psychiatric drugs in terms of efficacy and improved quality of life in a range of disorders.

Unexpectedly high prevalence of akathisia in cancer patients

Objectives:

Complications of neuropsychiatric disorders are often detected in cancer patients. Adjustment disorders, depression, or delirium are common psychiatric disorders in these patients, and drug-induced neuropsychiatric problems are sometimes referred for psychiatric consultation. Prochlorperazine and other antiemetic drugs that are phenothiazine derivates are also reported to cause akathisia due to the blockade of the dopamine receptor in the central nervous system, but the prevalence of akathisia in patients undergoing cancer treatment has not been reported. This study seeks to explore the prevalence of such drug-induced syndromes (e.g., akathisia) in this population.

Methods:

This present study was a prospective study. The subjects of this study were 483 consecutive patients with cancer who had been referred to the Department of Psychiatry in Kanagawa Prefecture Cancer Center from February 1, 2004, to November 30, 2005. Trained psychiatrists conducted a nonstructured psychiatric interview and neurologic examination to establish psychiatric diagnoses according to DSM-IV and the presence or absence of drug-induced extra pyramidal symptoms. The past and current medications used in their cancer treatment were also examined in detail for an accurate evaluation.

Results:

A psychiatric diagnosis was made in 420 (87.0%) of the 483 cancer patients examined, and akathisia, a drug-induced movement disorder, was unexpectedly prevalent among the patients; 20 of 420 (4.8%) patients had developed akathisia from an antiemetic drug, prochlorperazine.

Significance of results:

Diagnosing such adverse drug reactions may be difficult due to complicating factors in cancer treatment, and the inner restlessness observed in akathisia is likely to be regarded as a symptom of a primary psychiatric disorder. The authors suggest that oncologists should optimize the use of antiemetic drugs and be aware of akathisia as a possible complication of cancer treatment.

EPS profiles: the atypical antipsychotics are not all the same

Within the first few years after chlorpromazine began to be used to treat psychosis, it was observed that it could cause many kinds of neurologic reactions that resembled those seen in idiopathic Parkinson's disease. These reactions were termed "extrapyramidal side effects" (EPS) because of their resemblance to the signs of Parkinson's disease, which were associated with degeneration of the dopamine nerve tracks located in the extrapyramidal region of the central nervous system. Eventually this association of dopamine loss, antipsychotics, and parkinsonism became a central part of the dopamine hypothesis of schizophrenia. Unfortunately, this association was also used to support the hypothesis that EPS were absolutely necessary for antipsychotic efficacy--hence the term "neuroleptic" rather than "antipsychotic." This theory, now discredited, was used to justify the practice of inducing EPS as a means to gauge whether an antipsychotic would be effective. The demonstration that clozapine, an antipsychotic virtually devoid of EPS, has better efficacy for psychosis than any other "neuroleptic" disproved the theory that EPS were fundamentally linked to efficacy. Because the idea of a relationship between EPS and efficacy was so ingrained in clinical practice, clozapine was called "atypical." Our understanding of the relationship between EPS and antipsychotic response has come full circle. With the introduction of clozapine and other newer antipsychotics, it has become clear that EPS are harmful and serve no beneficial purpose. The availability of newer antipsychotics with a lower EPS burden means that, at least in theory, it is now possible to treat psychosis without EPS in the vast majority of patients. In practice, however, EPS remain a significant problem even in the era of atypical or second generation antipsychotics (SGAs). One limitation is that the concept of "atypicality," when used to denote antipsychotic efficacy without EPS, is a relative not an absolute concept. Because all of the post-clozapine SGAs still affect the dopamine D2 receptor, it may be more accurate to say these medications have lower EPS liabilities that the earlier "neuroleptic" antipsychotics; i.e., relatively fewer patients will get EPS at therapeutic doses of one of the newer medications and, when EPS do occur, they tend to be less severe. Nonetheless, reduced EPS are not the same as no EPS, and most of the newer antipsychotics can still cause EPS in some patients. The incidence of EPS differs among the SGAs, with risperidone associated with the most and clozapine and quetiapine with the fewest EPS. The likelihood of developing EPS with a first-line SGA depends not only on the specific agent, but also on the rapidity of dose escalation, the target dose, and the patient's intrinsic vulnerability to EPS. Even with the SGAs, clinicians should not be lulled into believing EPS cannot happen, but need to be able to recognize and manage both overt and subtle manifestations of EPS. This review discusses differences among the SGAs in EPS liability, relationships between dosing and type of EPS, and situations in which differences in EPS liability among the SGAs are clinically relevant.

Development of a simplified instrument for the diagnosis and grading of akathisia in a cohort of patients receiving prochlorperazine

Akathisia is a common side-effect of dopamine receptor D2 antagonists that often remains undiagnosed. Conventional diagnostic and grading instruments are cumbersome and can be difficult to remember and to use. To facilitate the Emergency Department (ED) assessment of acute drug-induced akathisia, I sought to derive and evaluate a simplified instrument using the database compiled from three prior studies of acute drug-induced akathisia. These studies had used a conventional Long instrument in the prospective assessment of 360 adult ED patients aged 17-65 years who received intravenous prochlorperazine (10 mg) in the treatment of headache or nausea and vomiting. The Short instrument was derived from the Long instrument using the Wilcoxon z-test to identify the individual findings most strongly associated with the diagnosis of akathisia. I then retrospectively applied the Short instrument to the cohort and used pairwise analyses to compare results obtained from both instruments. Sensitivity, specificity and receiver operating characteristic curves were used to analyze the impact of instrument form on diagnostic accuracy. The Long criteria diagnosed akathisia in 118 (32.8%; 95% confidence interval [CI] 28.0%-37.9%) patients and the Short diagnosed akathisia in 120 (33.3%; 95% CI 28.5%-38.5%). When akathisia was characterized categorically as either absent or present, the Short criteria agreed with the Long in 358 cases (99.4%; 95% CI 98.0%-99.9%). Treating the diagnoses established by the Long criteria as the gold standard, the Short instrument had a sensitivity of 100.0% (95% CI 96.9%-100%) and a specificity of 99.2% (95% CI 97.0%-99.9%). Regarding the accuracy of categorizing akathisia into four severity grades, the Short scale agreed in 325 of 360 cases (90.3%; 95% CI 86.7%-93.1%) and misgraded 35 cases (9.7%; 95% CI 6.9%-13.3%), 34 of which fell within one grade of the Long scale. The Short instrument is highly accurate in diagnosing acute drug-induced akathisia, in comparison with the Long criteria, in the ED setting. The Short instrument also provides fairly accurate grading of akathisia severity. This simplified instrument should facilitate the detection and treatment of akathisia in the ED.

Epidemiology of tardive dyskinesia: Is risk declining with modern antipsychotics?

Second-generation antipsychotic drugs (APDs), including aripiprazole, clozapine, olanzapine, risperidone, quetiapine, and ziprasidone dominate outpatient and inpatient clinical practice, having largely displaced the older neuroleptics. Modern APDs have relatively low risk for acute extrapyramidal syndromes characteristic of older neuroleptics, particularly acute dystonia and Parkinsonism, with variable risks of akathisia and the rare neuroleptic malignant syndrome. Anticipated reduction in risk of tardive dyskinesia (TD) is less well documented. Nearly 50 years after initial reports on TD, it is appropriate to reexamine the epidemiology of this potentially severe late adverse effect of long-term APD treatment in light of current research and practice. We compared recent estimates of incidence and prevalence of TD identified with some modern APDs to the epidemiology of TD in the earlier neuroleptic era. Such comparisons are confounded by complex modern APD regimens, uncommon exposure limited to a single modern APD, effects of previous exposure to typical neuroleptics, and neurological assessments that are rarely prospective or systematic. Available evidence suggests that the risk of TD may be declining, but longitudinal studies of patients never treated with traditional neuroleptics and exposed to only a single modern APD are required to quantify TD risks with specific drugs. Long-term use of APDs should continue to be based on research-supported indications, with regular specific examination for emerging TD.

Switching antipsychotics: an updated review with a focus on quetiapine

Atypical antipsychotics offer broader efficacy and improved tolerability compared with conventional agents. Many patients currently treated with conventional antipsychotics continue to experience persistent symptoms or troublesome side effects and may benefit from a change to one of the newer atypical agents. There are also significant differences in the side-effect profiles of the atypicals, such that a switch from one atypical agent to another could offer advantages to many patients. Unfortunately, many clinicians remain uncertain about the switching process and are reluctant to initiate change. The aim of this review is to identify the indications for a switch in antipsychotic therapy with a focus on recent switching data for the atypical antipsychotic, quetiapine. The clinical aspects of quetiapine's receptor binding characteristics are reviewed including the implications of the low D(2) antagonist properties that make quetiapine the treatment of choice when EPS persists with other atypical antipsychotics. Practical guidelines are given for managing the process of changeover, for avoiding pitfalls and for maximizing the chances of a successful switch. For example, when managing the antipsychotic crossover, it is important to consider the psychological effects of switching arising from symptom and side-effect changes. Finally, advice is provided on the assessments necessary when evaluating the success of a change in therapy, together with guidance on the optimal duration of treatment trials.