Intermittent neuroleptic treatment and risk for tardive dyskinesia: Curaçao Extrapyramidal Syndromes Study III

A new era in the diagnosis and treatment of tardive dyskinesia

Tardive dyskinesia (TD) is a heterogeneous, hyperkinetic movement disorder induced by dopamine-receptor blocking agents that presents a unique challenge in the treatment of psychosis. Although acceptance of TD as a serious consequence of antipsychotic treatment was resisted initially, subsequent research by many investigators in psychopharmacology contributed to a rich store of knowledge on many aspects of the disorder. While basic neuroscience investigations continue to deepen our understanding of underlying motor circuitry, past trials of potential treatments of TD focusing on a range of theoretical targets were often inconclusive. Development of newer antipsychotics promised to reduce the risk of TD compared to older drugs, but their improved tolerability unexpectedly enabled an expanding market that paradoxically both increased the absolute number of patients at risk and diminished attention to TD which was relegated to legacy status. Fortunately, development and approval of novel vesicular monoamine transporter inhibitors offered evidence-based symptomatic treatment of TD for the first time and rekindled interest in the disorder. Despite recent progress, many questions remain for future research including the mechanisms underlying TD, genetic predisposition, phenomenological diversity, whether new cases are reversible, how to implement best practices to prevent and treat TD, and whether the development of novel antipsychotics free of the risk of TD is attainable. We owe our patients the aspirational goal of striving for zero prevalence of persistent symptoms of TD in anyone treated for psychosis.

Clinical Phenotype of Tardive Dyskinesia in Bipolar Disorder

PURPOSE

Recognizing the negative impact that antipsychotic-induced movement disorders have on the quality of life and treatment outcomes in bipolar disorder (BD), this study aimed to assess clinical correlates and antipsychotic use patterns of tardive dyskinesia (TD+) in BD.

MATERIALS AND METHODS

Participants with and without TD were included. Clinical variables were compared using t-test and χ2 test. Antipsychotic use patterns in TD+, including number of trials, mean doses, and estimated cumulative exposure, were assessed in a case-only analysis.

RESULTS

The prevalence rate of TD was 5.1%. In comparison to the TD- group (n = 1074), TD+ participants (n = 58) were older, more likely to be female and have type I bipolar illness. There were 60.3% of the TD+ group that continued using antipsychotics at study entry and had a mean cumulative exposure to antipsychotics of 18.2 ± 15.6 years. Average dose, in haloperidol equivalents, was 5.9 ± 3.5 mg and 77.7% of the trials were second-generation antipsychotics.

CONCLUSIONS

This study confirms previously identified TD risk factors, such as age, sex, and bipolar subtype in a large BD cohort. Limitations included a cross-sectional design and the lack of tardive illness severity assessment. As atypical antipsychotics continue to be primary mood stabilization treatment, attempting to harmonize large data sets to identify additional biomarkers of tardive risk will optimize individualized care for patients with BD.

Clinical and demographic factors associated with early relapse in patients with schizophrenia: a naturalistic observation study

Schizophrenia is a chronic psychiatric disorder progressing in relapses. Identification of many factors that may potentially increase the risk of relapse will be an important step in preventing relapses. The aim of this study was to determine the rate of early relapse in patients with schizophrenia and possible risk factors related to early relapse. The sample of this prospective study with the naturalistic observation design consisted of 308 patients with schizophrenia. The cutoff value for early relapse was determined as 1 year. The mean age of participants was 37.38 ± 12.28 years and 66.6% of them were male (n = 205). The early relapse rate was 38.3%. The age younger than 35 [hazard ratio (HR) = 2.313; 95% confidence interval (CI), 1.518-3.526; P < 0.001], use of psychoactive substance (HR = 2.200; 95% CI, 1.407-3.440; P = 0.001), previous attempt of suicide (HR = 1.565; 95% CI, 1.028-2.384; P = 0.037), bad adherence to treatment (HR = 3.102; 95% CI, 1.358-7.086; P = 0.007), long-acting injectables (LAIs) antipsychotics in the treatment (HR = 0.534; 95% CI, 0.351-0.812; P = 0.003), combination typical-atypical antipsychotics (HR = 0.326; 95% CI, 0.131-0.807; P = 0.015), number of episodes (HR = 1.088; 95% CI, 1.043-1.134), and the score on the Side Effect factor of the Clinical Global Impressions Scale (HR = 1.826; 95% CI, 1.357-2.458; P < 0.001) were identified as the independent predictors of early relapse. It is remarkable that treatment bad adherence, use of psychoactive substance, no LAIs antipsychotics included in the treatment, and the no presence of the combination of typical and atypical antipsychotics are alterable predictors of early relapse.

Haloperidol-Induced Preclinical Tardive Dyskinesia Model in Rats

Haloperidol is a first-generation antipsychotic used in the treatment of psychoses, especially schizophrenia. This drug acts by blocking dopamine D2 receptors, reducing psychotic symptoms. Notwithstanding its benefits, haloperidol also produces undesirable impacts, in particular extrapyramidal effects such as tardive dyskinesia (TD), which limit the use of this and related drugs. TD is characterized by repetitive involuntary movements occurring after chronic exposure therapy with haloperidol. Symptoms most commonly manifest in the orofacial area and include involuntary movements, tongue protrusion, pouting lips, chewing in the absence of any object to chew, and facial grimacing. The most serious aspect of TD is that it may persist for months or years after drug withdrawal and is irreversible in some patients. This unit, aimed at facilitating the study of TD, describes methods to induce TD in rats using haloperidol, as well as procedures for evaluating the animals's TD-related symptoms. © 2019 by John Wiley & Sons, Inc.

Evidence-based guidelines for the pharmacological treatment of schizophrenia: Updated recommendations from the British Association for Psychopharmacology

These updated guidelines from the British Association for Psychopharmacology replace the original version published in 2011. They address the scope and targets of pharmacological treatment for schizophrenia. A consensus meeting was held in 2017, involving experts in schizophrenia and its treatment. They were asked to review key areas and consider the strength of the evidence on the risk-benefit balance of pharmacological interventions and the clinical implications, with an emphasis on meta-analyses, systematic reviews and randomised controlled trials where available, plus updates on current clinical practice. The guidelines cover the pharmacological management and treatment of schizophrenia across the various stages of the illness, including first-episode, relapse prevention, and illness that has proved refractory to standard treatment. It is hoped that the practice recommendations presented will support clinical decision making for practitioners, serve as a source of information for patients and carers, and inform quality improvement.

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.

Treatment of Tardive Dyskinesia: A General Overview with Focus on the Vesicular Monoamine Transporter 2 Inhibitors

Tardive dyskinesia (TD) encompasses the spectrum of iatrogenic hyperkinetic movement disorders following exposure to dopamine receptor-blocking agents (DRBAs). Despite the advent of atypical or second- and third-generation antipsychotics with a presumably lower risk of complications, TD remains a persistent and challenging problem. Prevention is the first step in mitigating the risk of TD, but early recognition, gradual withdrawal of offending medications, and appropriate treatment are also critical. As TD is often a persistent and troublesome disorder, specific antidyskinetic therapies are often needed for symptomatic relief. The vesicular monoamine transporter 2 (VMAT2) inhibitors, which include tetrabenazine, deutetrabenazine, and valbenazine, are considered the treatment of choice for most patients with TD. Deutetrabenazine-a deuterated version of tetrabenazine-and valbenazine, the purified parent product of one of the main tetrabenazine metabolites, are novel VMAT2 inhibitors and the only drugs to receive approval from the US FDA for the treatment of TD. VMAT2 inhibitors deplete presynaptic dopamine and reduce involuntary movements in many hyperkinetic movement disorders, particularly TD, Huntington disease, and Tourette syndrome. The active metabolites of the VMAT2 inhibitors have high affinity for VMAT2 and minimal off-target binding. Compared with tetrabenazine, deutetrabenazine and valbenazine have pharmacokinetic advantages that translate into less frequent dosing and better tolerability. However, no head-to-head studies have compared the various VMAT2 inhibitors. One of the major advantages of VMAT2 inhibitors over DRBAs, which are still being used by some clinicians in the treatment of some hyperkinetic disorders, including TD, is that they are not associated with the development of TD. We also briefly discuss other treatment options for TD, including amantadine, clonazepam, Gingko biloba, zolpidem, botulinum toxin, and deep brain stimulation. Treatment of TD and other drug-induced movement disorders must be individualized and based on the severity, phenomenology, potential side effects, and other factors discussed in this review.

The psychopharmacology of catatonia, neuroleptic malignant syndrome, akathisia, tardive dyskinesia, and dystonia

Although highly prevalent, motor syndromes in psychiatry and motor side effects of psychopharmacologic agents remain understudied. Catatonia is a syndrome with specific motor abnormalities that can be seen in the context of a variety of psychiatric and somatic conditions. The neuroleptic malignant syndrome is a lethal variant, induced by antipsychotic drugs. Therefore, antipsychotics should be used with caution in the presence of catatonic signs. Antipsychotics and other dopamine-antagonist drugs can also cause motor side effects such as akathisia, (tardive) dyskinesia, and dystonia. These syndromes share a debilitating impact on the functioning and well-being of patients. To reduce the risk of inducing these side effects, a balanced and well-advised prescription of antipsychotics is of utmost importance. Clinicians should be able to recognize motor side effects and be knowledgeable of the different treatment modalities.

Tardive dyskinesia update: the syndrome

Tardive dyskinesia is a common iatrogenic neurological and neurobehavioural syndrome associated with the use of antidopaminergic medication, especially antipsychotics. Prior to the introduction of the newer antipsychotics in the 1990s, it was one of the major areas of psychiatric research but interest waned as the new drugs were reputed to have a reduced liability to extrapyramidal adverse effects in general, a claim now discredited by numerous pragmatic research studies. Early small-scale short-term prevalence studies were presented as evidence to support the assumption that patients on the newer drugs did indeed have a lower prevalence of tardive dyskinesia but recent large-scale review of studies with patients exposed for longer suggest that things have not changed. This article presents a clinical overview of a complex and varied syndrome in terms of its phenomenology, epidemiology and risk factors; a companion article will consider treatment. This overview aims to highlight tardive dyskinesia once again, especially to practitioners who have trained in an environment where this was considered mainly in historical terms.

LEARNING OBJECTIVES

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DECLARATION OF INTEREST

None.

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.

No Effect of Dose Adjustment to the CYP2D6 Genotype in Patients With Severe Mental Illness

Background: The CYP2D6 enzyme is involved in the metabolism of numerous psychopharmacological drugs. Guidelines recommend how to adjust the dose of medication based on the CYP2D6 genotype. Aims: To evaluate the effect of dose adjustment to the CYP2D6 genotype and phenotype, in patients with severe mental illness (SMI) already receiving psychopharmacological treatment. Methods: A total of 269 psychiatric patients (on the island Curaçao) receiving antipsychotic treatment were genotyped for CYP2D6. Of these, 45 patients were included for dose adjustment according to the clinical guideline of the Royal Dutch Association for the Advancement of Pharmacy, i.e., 17 CYP2D6 poor metabolizers, 26 intermediate metabolizers, and 2 ultrarapid metabolizers. These 45 patients were matched for age, gender, and type of medication with a control group of 41 patients who were CYP2D6 extensive metabolizers (i.e., with a normal CYP2D6 function). At baseline and at 4 months after dose adjustment, subjective experience, psychopathology, extrapyramidal side-effects, quality of life, and global functioning were assessed in these two groups. Results: At baseline, there were no differences between the groups regarding the prescribed dosage of antipsychotics, the number of side-effects, psychiatric symptoms, global functioning, or quality of life. After dose adjustment, no significant improvement in these parameters was reported. Conclusion: In psychiatric patients with SMI already receiving antipsychotic treatment, dose adjustment to the CYP2D6 genotype or phenotype according to the guidelines showed no beneficial effect. This suggests that dose adjustment guidelines are currently not applicable for patients already using antipsychotics. ClinicalTrials.gov: Cost-effectiveness of CYP2D6 and CYP2C19 Genotyping in Psychiatric Patients in Curacao; Identifier: NCT02713672; https://clinicaltrials.gov/ct2/show/NCT02713672?term=CYP2D6&rank=5.

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.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

The nature of relapse in schizophrenia

BACKGROUND

Multiple relapses characterise the course of illness in most patients with schizophrenia, yet the nature of these episodes has not been extensively researched and clinicians may not always be aware of important implications.

METHODS

We critically review selected literature regarding the nature and underlying neurobiology of relapse.

RESULTS

Relapse rates are very high when treatment is discontinued, even after a single psychotic episode; a longer treatment period prior to discontinuation does not reduce the risk of relapse; many patients relapse soon after treatment reduction and discontinuation; transition from remission to relapse may be abrupt and with few or no early warning signs; once illness recurrence occurs symptoms rapidly return to levels similar to the initial psychotic episode; while most patients respond promptly to re-introduction of antipsychotic treatment after relapse, the response time is variable and notably, treatment failure appears to emerge in about 1 in 6 patients. These observations are consistent with contemporary thinking on the dopamine hypothesis, including the aberrant salience hypothesis.

CONCLUSIONS

Given the difficulties in identifying those at risk of relapse, the ineffectiveness of rescue medications in preventing full-blown psychotic recurrence and the potentially serious consequences, adherence and other factors predisposing to relapse should be a major focus of attention in managing schizophrenia. The place of antipsychotic treatment discontinuation in clinical practice and in placebo-controlled clinical trials needs to be carefully reconsidered.

Drug-induced movement disorders

This comprehensive review covers approaches for both the recognition and management of drug-induced movement disorders. Pharmacotherapeutic approaches for treating akathisia, dystonia, Parkinsonism and tardive dyskinesia are explored. The importance of early detection via periodic assessment is discussed.

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.

The role of dopamine D3, 5-HT2A and 5-HT2C receptor variants as pharmacogenetic determinants in tardive dyskinesia in African-Caribbean patients under chronic antipsychotic treatment: Curacao extrapyramidal syndromes study IX

Tardive dyskinesia (TD) is associated with polymorphisms of the dopamine D(3), serotonin 2A and 2C receptors (DRD3, HTR2A and HTR2C, respectively). This study investigated the possible relationship between TD and the polymorphisms Ser9Gly (DRD3), 102T>C (HTR2A), -1438G>A(HTR2A) and Cys23Ser (HTR2C) in African-Caribbean inpatients. One hundred and twenty-six patients under chronic antipsychotic treatment were genotyped. The assessment of TD was carried out with the abnormal involuntary movement scale (AIMS). The relationships between the carriership of the least frequent alleles and the respective orofaciolingual dyskinesia (TDof) (sum of the items 1-4 of the AIMS), limb-truncal dyskinesia (TDlt) (sum of items 5-7 of the AIMS) and TD (sum of items 1-7 of the AIMS) were analyzed with ANCOVA, comparing means with age as a covariate and stratification for carriers and non-carriers of the mutations. In addition, we conducted pre-planned t-tests to compare AIMS values of carriers of the combinations of alleles versus the corresponding non-carriers. In the study population, females with 9Ser carriership exhibited higher AIMS values than non-carriers. Male subjects with 9Ser carriership in combination with 23Ser or -1438A carriership exhibited higher AIMS values. In male patients also, the combination of 23Ser and -1438A carriership increased TD. The study clearly shows that the African-Caribbean population differs from the Caucasian population with regard to the association of TD with the polymorphisms studied and suggests that the association of TD with the studied polymorphisms of the 5-HT(2C) and probably of the 5-HT(2A) receptor are the result of a changed susceptibility of the patients, independent of the action of the antipsychotics on these receptors.

NonParkinsonism Movement Disorders in the Elderly

OBJECTIVE

The primary objective of this article is to review the clinical presentation and pharmacologic management of essential tremor and tardive dyskinesia.

DATA SOURCES

The MEDLINE (1966-August 2005), Cochrane Database of Systematic Reviews, and International Pharmaceutical Abstracts (1970-August 2005) databases were searched for original research and review articles published in English. The search terms were essential tremor and tardive dyskinesia. Reference lists from articles were also consulted.

DATA SYNTHESIS

Essential tremor is most commonly manifested as a postural or action tremor of the upper extremities. Midline regions such as the head and voice are also commonly affected. Based on review of the literature, propranolol and primidone are the current pharmacologic mainstays for treating essential tremor of the upper extremities. The choice of agent depends on patient-specific factors such as underlying medical conditions. Other agents with demonstrated efficacy include gabapentin and topiramate. Benzodiazepines are effective adjunctive agents, but should be utilized judiciously in the elderly. Botulinum toxin is effective for essential tremor of the voice and head. Surgery is very effective, but may not be appropriate in the frail elderly and should be avoided in the presence of cognitive impairment. Tardive dyskinesia is characterized by involuntary choreoathetoid movements of the orofacial region. For the management of tardive dyskinesia, emphasis is placed on primary prevention and early recognition of signs and symptoms. In some cases, discontinuation of the offending agent can result in reversal of symptoms. If a conventional neuroleptic is the causative agent, switching to an atypical antipsychotic may be helpful. Overall, few treatments have proven to be consistently useful. Other agents that may be helpful include acetylcholinesterase inhibitors, amantadine, baclofen, benzodiazepines, branched chain amino acids, gabapentin, levetiracetam, pyridoxine, verapamil, and vitamin E.

CONCLUSION

Current pharmacologic agents for essential tremor can be expected to provide partial benefit. However, agents for the symptomatic management of tardive dyskinesia are limited, and additional research is warranted in this area.

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

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

Worsening of psychosis in schizophrenia is longitudinally associated with tardive dyskinesia in the European Schizophrenia Outpatient Health Outcomes study

OBJECTIVE

The objective of the study was to examine if worsening of psychosis predicts the emergence of tardive dyskinesia (TD).

METHOD

Global measures of TD and Clinical Global Impression (CGI) overall symptom severity score were rated in 4 assessments in 12 months. In a risk set free of TD at baseline, associations between TD onset and change in CGI scores were assessed using Cox proportional hazard regression.

RESULTS

A total of 8,620 patients yielded 23,565 follow-up observations, 8.8% of which represented a worsening in CGI overall symptom severity relative to the previous observation, yielding an incidence of TD of 5.2%, compared with 2.7% in observations without worsening of psychopathology (rate ratio, 1.9; 95% confidence interval, 1.3-2.7). Incidence of TD was longitudinally associated with a worsening of the CGI overall symptom severity in the months preceding TD onset (adjusted hazard ratio over 6 levels of CGI score, 1.3; 95% confidence interval, 1.1-1.4).

CONCLUSION

Worsening in overall psychopathology in schizophrenia is longitudinally associated with the emergence of TD as measured by CGI overall symptom severity.

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.

Antipsychotic-induced tardive dyskinesia and the Ser9Gly polymorphism in the DRD3 gene: a meta analysis

BACKGROUND

A polymorphic site in the gene encoding the dopamine 3 receptor (DRD3) resulting in a serine (Ser) into glycine (Gly) substitution has been shown to affect dopamine binding affinity, and may contribute to individual differences in susceptibility to antipsychotic-induced tardive dyskinesia (TD).

METHODS

A Medline, EMBASE and PsychINFO search of literature published between 1976 and March 2005 yielded 11 studies from which data were extracted for calculation of pooled estimates using meta-analytic techniques.

RESULTS

The Gly allele increased the risk relative to the Ser allele (OR=1.17; 95% CI: 1.01-1.37) with evidence of publication bias. No significant genotype effects were apparent.

CONCLUSIONS

TD may be associated with functional variation in the DRD3 allele. However, caution is required in interpreting this finding, as there is evidence of publication bias, genetic methodology has shortcomings, and the relation between antipsychotics, schizophrenia and TD is complex.

Tardive dyskinesia in the era of typical and atypical antipsychotics. Part 2: Incidence and management strategies in patients with schizophrenia

OBJECTIVE

Tardive dyskinesia (TD), the principal adverse effect of long-term conventional antipsychotic treatment, can be debilitating and, in many cases, persistent. We sought to explore the incidence and management of TD in the era of atypical antipsychotics because it remains an important iatrogenic adverse effect.

METHODS

We conducted a review of TD incidence and management literature from January 1, 1965, to January 31, 2004, using the terms tardive dyskinesia, management, therapy, neuroleptics, antipsychotics, clozapine, olanzapine, risperidone, quetiapine, ziprasidone, and aripiprazole. Additional articles were obtained by searching the bibliographies of relevant references. We considered articles that contributed to the current understanding of both the incidence of TD with atypical antipsychotics and management strategies for TD.

RESULTS

The incidence of TD is significantly lower with atypical, compared with typical, antipsychotics, but cases of de novo TD have been identified. Evidence suggests that atypical antipsychotic therapy ameliorates long-standing TD. This paper outlines management strategies for TD in patients with schizophrenia.

CONCLUSION

The literature supports the recommendation that atypical antipsychotics should be the first antipsychotics used in patients who have experienced TD as a result of treatment with conventional antipsychotic agents. The other management strategies discussed may prove useful in certain patients.

Continuous but not intermittent olanzapine infusion induces vacuous chewing movements in rats

BACKGROUND

Continuous, but not intermittent, infusion with a conventional antipsychotic (haloperidol, HAL) can induce the vacuous chewing movement (VCM) syndrome in rats. The objective of this study was to determine whether continuous, versus intermittent, olanzapine (OLZ) infusion differently affects the development of VCMs.

METHODS

Experiment 1: Animals were treated with 7.5 mg/kg/day of OLZ or vehicle (VEH) via either minipump (MP) or daily subcutaneous (SC) injections for 8 weeks. Experiment 2: A separate group of rats were treated with 15 mg/kg/day of OLZ, or 1 mg/kg/day of HAL or VEH via MP for 8 weeks. Dopamine D2 receptor occupancy levels were measured, ex vivo, with [3H]-raclopride.

RESULTS

Experiment 1: Rats receiving 7.5 mg/kg/day of OLZ via MP (51% D2 occupancy), but not those receiving the same dose via daily SC injections (94% peak D2 occupancy), showed significant VCM levels compared with control animals (p = .02). Experiment 2: Both OLZ (67% D2 occupancy) and HAL (79% D2 occupancy) led to similar increases in VCMs compared with VEH (p = .005).

CONCLUSIONS

This study provides strong evidence that even an atypical antipsychotic like OLZ, which rarely gives rise to tardive dyskinesia in the clinic, can lead to the VCM syndrome in rats if the antipsychotic is administered in a method (via MP) that leads to continuous presence of the drug in the brain.

Les traitements adjuvants au cours de l’épisode maniaque

When treating patients with manic states, the physician has to deal with at least two main Issues. First, the therapeutic decision has to be rapid because of the unpredictability of its immediate course. This concerns often results in polypharmacy with adjunct treatments. However, the therapeutic choice has to be cautious since part of the treatment will be maintained for prophylaxis. According to recent guidelines, the use of monotherapy with mood stabilisers during acute manic states concerns only few patients with mostly hypomania to moderate mania. Up to date, antipsychotics and benzodiazepines are considered as adjunct treatment in mania with psychotic symptoms or hostility. However, survey studies show that antipsychotics are widely used as adjunct treatments to mood stabilisers, indeed beyond the indications held by the guidelines. Our objective was to describe the clinical situations justifying the addition of an adjunct treatment during acute mania and to clear up from published data, the advantages and the inconveniences of combining antipsychotics and/or benzodiazepines with a mood stabilisers in order to define differentiated indications. Mania associated with either agitation, sleep disturbances or psychotic symptoms requires most of the time to combine mood stabiliser and respectively, sedative and/or anxiolytic, hypnotic or anti-psychotic treatments. Patients suffering from mania associated with other disorders need specific treatment adjustment and combination related to their medical condition. Adjunctive conventional antipsychotic remains widely used in first intention treatment. The conventional antipsychotic is often prescribed alone in the first weeks prior to the association with a mood stabiliser. Nevertheless there are controversies in the literature about their efficiency and their delay of action with regard to other treatments. When the conventional antipsychotic is a part of their initial treatment, manic patients remain taking them when discharged from hospital and are still taking them after 6 Months in a great percentage of the cases. The adverse events with conventional antipsychotic are numerous and severe enough in bipolar patients to restrict their use in first intention mainly to psychotic mania. Moreover, there are evidences for higher sensitivity to adverse effects of the conventional antipsychotics in manic patients. When agitation in acute mania requires an adjunct to mood stabiliser, the conventional antipsychotic treatment could be use for over-excitation without catatonic features and with particular care with the risk of akathisia. Long term effects of conventional antipsychotics, especially on depressive recurrences, should argue to stop them as soon as possible. Since the safety of adjunctive new antipsychotics with mood stabilisers seems until now acceptable, its indication should be limited to acute psychotic manias. Adjunctive benzodiazepine, should be evaluated in the various types of mania with specific concerns with comorbidity frequently met in consultation-liaison psychiatry. Benzodiazepines plus mood stabilisers may be the treatment of choice for the manias in which anxious state, catatonic symptoms or sleeplessness.

Mouvements anormaux d’origine médicamenteuse : les syndromes tardifs

Persistent drug-induced movement disorders (tardive syndromes) remain an important clinical problem and consist of a variety of involuntary movements appearing in a patient exposed to a dopamine-blocking agent. The current state of knowledge on this topic is summarised in this article. Clinical aspects (tardive dyskinesia, tardive dystonia and other forms), prevalence, risk factors, prevention and management are discussed.

Differential effects of within-day continuous vs. transient dopamine D2 receptor occupancy in the development of vacuous chewing movements (VCMs) in rats

Accumulating evidence suggests that antipsychotics (APs) that lead to sustained blockade of dopamine D(2) receptors are more likely to induce acute extrapyramidal side effects (EPS) compared to APs that only occupy D(2) receptors transiently. It is unclear, however, whether a similar relationship exists for long-term AP-induced motoric side effects like tardive dyskinesia (TD). The objective of this study was to ascertain whether transient (via daily subcutaneous (s.c.) injections) vs continuous (via osmotic minipump) AP-induced D(2) receptor occupancy differentially affects the development of haloperidol-induced vacuous chewing movements (VCMs), an animal model of TD. Six groups of 12 rats received 0.1, 0.25, or 1 mg/kg of haloperidol or vehicle (n=36) via osmotic minipump (to provide within-day sustained) or daily s.c. injection (within-day transient) for 8 weeks. VCMs were measured on a weekly basis and D(2) occupancy levels were measured in vivo using [(3)H]-raclopride at the end of the experiment. Minipump-treated rats developed HAL dose-dependent D(2) occupancies of 0.1 mg/kg/day (57%), 0.25 mg/kg/day (70%), and 1 mg/kg/day (88%). S.C.-treated rats also developed HAL dose-dependent D(2) occupancies of 0.1 mg/kg/day (83% peak, 3% trough), 0.25 mg/kg/day (89% peak, 0% trough), and 1 mg/kg/day (94% peak, 17% trough). A total of 43% of rats given 0.25 and 1 mg/kg/day of HAL via minipump developed high VCMs compared to only 8% of the rats given the same doses via daily s.c. injections. The 0.1 mg/kg dose did not give rise to VCMs beyond vehicle levels regardless of the route of administration. These findings support the contention that D(2) occupancy levels induced by chronic HAL must be high and sustained through the day before significant risk of VCMs, and perhaps also TD, emerges.

Nithsdale Schizophrenia Surveys 23: movement disorders. 20-year review

BACKGROUND

In the past 10 years the new atypical antipsychotic drugs have stimulated further interest in the pharmacological management of schizophrenia. The risk of movement disorders has been reported to be less with these new agents.

AIMS

To examine the current prevalence of movement disorders among all people with schizophrenia in a discrete geographical area, to compare the prevalence in patients receiving and not receiving atypical antipsychotic drugs; and to compare current prevalence with prevalence over the past 20 years.

METHOD

In Nithsdale, south-west Scotland, in 1999/2000, we replicated previous studies by using the Abnormal Involuntary Movements Scale, Simpson-Angus scale and Barnes Akathisia Rating Scale to measure tardive dyskinesia, parkinsonism and akathisia, respectively. Mental state was assessed by the Positive and Negative Syndrome Scale.

RESULTS

In 136 patients the prevalence of probable tardive dyskinesia was 43%, of parkinsonism 35% and of akathisia 15%. Parkinsonism was present as often in those receiving atypicals as in those receiving standard oral antipsychotics. The prevalence of tardive dyskinesia has doubled over 20 years.

CONCLUSIONS

Movement disorders remain significant problems for patients despite the introduction of atypical antipsychotic drugs.

The vacuous chewing movement (VCM) model of tardive dyskinesia revisited: is there a relationship to dopamine D(2) receptor occupancy?

Tardive dyskinesia (TD) is a late side effect of long-term antipsychotic use in humans, and the vacuous chewing movement (VCM) model has been used routinely to study this movement disorder in rats. Recent receptor occupancy studies in humans and rats have found that antipsychotics given in doses which lead to moderate levels of D(2) receptor blockade can achieve optimal clinical response while minimizing the emergence of acute motor side effects. This suggests that clinicians may have been using inappropriately high doses of antipsychotics. A review of the existing VCM literature indicates that most animal studies have similarly employed antipsychotic doses that are high, i.e. doses that lead to near complete D(2) receptor saturation. To verify whether the incidence or severity of VCMs would decrease with lower antipsychotic doses, we conducted initial experiments with different doses of haloperidol (HAL) given either as repeated daily injections or as depot injections over the course of several weeks. Our results demonstrate that (1) the incidence of VCMs is significantly related to HAL dose, and (2) significant levels of VCMs only emerge when haloperidol is continually present. These findings are consistent with the possibility that total D(2) occupancy, as well as 'transience' of receptor occupation, may be important in the development of late-onset antipsychotic-induced dyskinetic syndromes.

Reasoning about the optimal duration of prophylactic antipsychotic medication in schizophrenia: evidence and arguments

OBJECTIVE

To review evidence-based literature regarding the necessary duration of antipsychotic relapse prevention in schizophrenia and related psychoses.

METHOD

A computerized search was performed on Medline, Embase Psychiatry and PsycLIT which covered the period 1974-99. We also used cross-references.

RESULTS

Although schizophrenia refers mainly to an intrinsic biological vulnerability, only maintenance studies with a follow-up of 2 years at most are available. Relapses appear unpredictable and occur even after long-term successful remission during antipsychotic treatment.

CONCLUSION

Since rehabilitation efforts have effects only after long-term endeavours, antipsychotic relapse prevention should be maintained for long periods. It is reasonable to treat patients suffering from schizophrenia and related psychoses for longer periods than indicated by the current guidelines.