Depression-dependent exacerbation of tardive dyskinesia

Prevalence, clinical correlates and risk factors associated with Tardive Dyskinesia in Chinese patients with schizophrenia

Tardive Dyskinesia (TD) is a serious, nonrhythmic and iatrogenic movement disorder, and is a common comorbidity in patients with schizophrenia (SZ). The main goal of this study was to investigate the prevalence, clinical correlates, and risk factors of TD in Chinese patients with chronic SZ, which has not been fully studied. This study adopted a cross-sectional design. A total of 901 Chinese inpatients with SZ were recruited between 2008 and 2011. We used the Abnormal Involuntary Movement Scale (AIMS) to measure the severity of TD, and the Positive and Negative Syndrome Scale (PANSS) was used to measure the psychopathological symptoms of SZ. Blood samples were also collected for routine blood tests, including the levels of triglyceride (TG), cholesterol (CHO), HDL-cholesterol (HDL-CHO), LDL-cholesterol (LDL-CHO), Apolipoprotein A1 (ApoA1), and Apolipoprotein B (ApoB). Overall, 36% of patients with SZ had TD. Compared with the non-TD patients, the TD patients were more likely to be men, had older age, lower education level, higher smoking rate, higher hospitalization frequency, and longer duration of illness (DOI). Further, compared with the non-TD patients, the TD patients had higher PANSS total, PANSS negative subscale, and cognitive subscale scores, but had lower depressive subscale scores and lower mean levels of metabolic biomarkers, including TG, CHO, HDL-CHO, LDL-CHO, ApoA1 and ApoB. Moreover, binary regression analysis showed that antipsychotic type, BMI, gender, age, HDL-CHO, and ApoB were associated with TD. Our findings indicate that TD is a common movement disorder in patients with chronic SZ, with certain demographic and clinical variables being risk factors for the development of TD.

Motor dysfunction as an intermediate phenotype across schizophrenia and other psychotic disorders: Progress and perspectives

Primary motor abnormalities (PMA), as found in patients with schizophrenia, are quantitatively and qualitatively distinct markers of motor system abnormalities. PMA have been often referred to phenomena that are present across schizophrenia-spectrum disorders. A dysfunction of frontoparietal and subcortical networks has been proposed as core pathophysiological mechanism underlying the expression of PMA. However, it is unclear at present if such mechanisms are a common within schizophrenia and other psychotic disorders. To address this question, we review recent neuroimaging studies investigating the neural substrates of PMA in schizophrenia and so-called "nonschizophrenic nonaffective psychoses" (NSNAP) such as schizophreniform, schizoaffective, brief psychotic, and other unspecified psychotic disorders. Although the extant data in patients with schizophrenia suggests that further investigation is warranted, MRI findings in NSNAP are less persuasive. It is unclear so far which PMA, if any, are characteristic features of NSNAP or, possibly even specific for these disorders. Preliminary data suggest a relationship between relapsing-remitting PMA in hyper-/hypokinetic cycloid syndromes and neurodegenerative disorders of the basal ganglia, likely reflecting the transnosological relevance of subcortical abnormalities. Despite this evidence, neural substrates and mechanisms underlying PMA that are common in schizophrenia and NSNAP cannot be clearly delineated at this stage of research. PMA and their underlying brain circuits could be promising intermediate phenotype candidates for psychotic disorders, but future multimodal neuroimaging studies in schizophrenia and NSNAP patients and their unaffected first-degree relatives are needed to answer fundamental transnosologic questions.

Pyridoxal 5 phosphate for neuroleptic-induced tardive dyskinesia

BACKGROUND

Tardive dyskinesia is a chronic and disabling abnormal movement disorder affecting the muscles of the face, neck, tongue and the limbs. It is a common side effect of long-term antipsychotic medication use in individuals with schizophrenia and other related psychotic disorders. While there are no known effective treatments for tardive dyskinesia to date, some reports suggest that pyridoxal 5 phosphate may be effective in reducing the severity of tardive dyskinesia symptoms.

OBJECTIVES

To determine the effectiveness of pyridoxal 5 phosphate (vitamin B6 or Pyridoxine or Pyridoxal phosphate) in the treatment of neuroleptic-induced tardive dyskinesia among people with schizophrenia and other related psychotic disorders.

SEARCH METHODS

The Cochrane schizophrenia group's register of clinical trials was searched (January 2013) using the phrase: [*Pyridoxal* OR *Pyridoxine* OR *P5P* OR *PLP* OR *tardoxal* OR *Vitamin B6* O *Vitamin B 6* R in title, abstract or index terms of REFERENCE, or interventions of STUDY. References of relevant identified studies were handsearched and where necessary, the first authors of relevant studies were contacted.

SELECTION CRITERIA

Studies described as randomised controlled trials comparing the effectiveness pyridoxal 5 phosphate with placebo in the treatment of neuroleptic-induced tardive dyskinesia among patients with schizophrenia.

DATA COLLECTION AND ANALYSIS

The review authors independently extracted data from each selected study. For dichotomous data, we calculated risk ratios (RR) and their 95% confidence intervals (CIs) on an intention-to-treat basis based on a fixed-effect model. For continuous data, we calculated mean differences (MD) with 95% CIs, again based on a fixed-effect model. We assessed risk of bias for each included study and used GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach to rate quality of evidence.

MAIN RESULTS

Of the 12 records retrieved by the search, three trials published in 2001, 2003 and 2007, involving 80 inpatients with schizophrenia, aged 18 to 71 years, admitted in a psychiatric facility and followed up for a period nine weeks to 26 weeks, were included. Overall, pyridoxal 5 phosphate produced a significant improvement in tardive dyskinesia symptoms when compared with placebo, assessed by a change in Extrapyramidal Symptoms Rating Scale (ESRS) scores from baseline to the end of the first phase of the included studies (2 RCTs n = 65, RR 19.97, CI 2.87 to 139.19, low quality evidence). The endpoint tardive dyskinesia score (a measure of its severity) assessed with the ESRS, was significantly lower among participants on pyridoxal 5 phosphate compared to those on placebo (2 RCTs n = 60, MD -4.07, CI -6.36 to -1.79, low quality evidence).It was unclear whether pyridoxal 5 phosphate led to more side effects (n = 65, 2 RCTs, RR 3.97, CI 0.20 to 78.59, low quality evidence) or caused deterioration in tardive dyskinesia symptoms when compared to placebo (n = 65, 2 RCTs, RR 0.16, CI 0.01 to 3.14, low quality evidence). Five participants taking pyridoxal 5 phosphate withdrew from the study because they were not willing to take more medications while none of the participants taking placebo discontinued their medications (n = 65, 2 RCTs, RR 8.72, CI 0.51 to 149.75, low quality evidence).There was no significant difference in the endpoint positive and negative psychiatric symptoms scores, measured using the Positive and Negative symptoms Scale (PANSS) between participants taking pyridoxal 5 phosphate and those taking placebo. For the positive symptoms: (n = 15, 1 RCT, MD -1.50, CI -4.80 to 1.80, low quality evidence). For negative the symptoms: (n = 15, 1 RCT, MD -1.10, CI -5.92 to 3.72, low quality evidence).

AUTHORS' CONCLUSIONS

Pyridoxal 5 phosphate may have some benefits in reducing the severity of tardive dyskinesia symptoms among individuals with schizophrenia. However, the quality of evidence supporting the effectiveness of pyridoxal 5 phosphate in treating tardive dyskinesia is low, based on few studies, short follow-up periods, small sample sizes and inadequate adherence to standardised reporting guidelines for randomised controlled trials among the included studies.

Spontaneous parkinsonism in antipsychotic-naive patients with first-episode psychosis

OBJECTIVE

The purpose of this study was to establish rates of spontaneous parkinsonism (SP) among the different types of psychosis. We hypothesized that the rate would be higher among persons with affective symptoms.

METHODS

We included in the study consecutive patients admitted to a first-episode psychosis intervention program. We recorded sociodemographic data from interviews with patients and caregivers and from medical records. We used the Simpson-Angus Rating Scale at baseline to assess parkinsonism and a diagnosis of SP was established if the Simpson-Angus score was > or = 0.3.

RESULTS

A total of 174 patients were examined; of these, only 4 (2.3%; 2 Chinese women, 1 Chinese man, and 1 Malay man) had SP. There was a significant difference in the rates of SP in patients with affective psychosis and schizoaffective disorder, compared with those with nonaffective psychoses (15.4% vs 1.2%; chi2 = 10.7, P = 0.001). The 2 groups did not differ significantly in age, duration of untreated psychosis, or sex distribution.

CONCLUSIONS

The rate of SP in Asian patients with first-episode psychosis was low, and it was significantly higher in those with affective symptoms.

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.

Neurogenesis and depression

The recognition that the brain continues to generate new neurons well into adulthood has made a marked impact on the field of neuroscience in general and specifically on neurobiological models of the pathogenesis of major depression. Stress, neuroendocrine activation, neurotransmitter systems, and other factors can down-regulate the process of neurogenesis and may contribute to certain morphological changes seen in depression. Evidence is emerging that antidepressant treatments may mitigate these effects by stimulating neurogenesis in particular regions of the brain. This review introduces the reader to recent literature on neurogenesis as it relates to the understanding and treatment of depression.

The current status of tardive dyskinesia

OBJECTIVE

This paper aims to provide an overview of the current knowledge on neuroleptic-induced tardive dyskinesia (TD) in relation to its clinical features, risk factors, pathophysiology and management.

METHOD

The published literature was selectively reviewed and assessed.

RESULTS

Tardive diskinesia is a common neurological side-effect of neuroleptic medication, the cumulative incidence of which increases with increasing duration of treatment. Its clinical manifestations are diverse and subsyndromes have been described. Many risk factors for TD are now recognised, but increasing age remains pre-eminent as a risk factor. The pathophysiology of TD is not completely understood. Of the neurotransmitter hypotheses, the dopamine receptor supersensitivity hypothesis and the gamma-aminobutyric acid insufficiency hypothesis are the main contenders. There is increasing recognition that TD may in fact be caused by neuroleptic-induced neuronal toxicity through free radical and excitotoxic mechanisms. The occurrence of spontaneous dyskinesias in schizophrenic patients and even healthy subjects suggests that neuroleptics act on a substratum of vulnerability to dyskinesia. As no effective treatment for TD is available, the primary emphasis is on prevention. Many drugs can be tried to reduce symptoms in established cases. The increasing use of atypical neuroleptics has raised the possibility of a lower incidence of TD in the future.

CONCLUSIONS

After four decades of clinical recognition, the pathophysiology of TD is still not understood and no effective treatment is available. Its prevention with the optimal usage of currently available drugs and regular monitoring of patients on long-term neuroleptic treatment remain the best strategies to reduce its impact.

Managing antipsychotic-induced acute and tardive dystonia

Antipsychotic-induced extrapyramidal adverse effects continue to be a serious problem in the treatment of psychotic disorders. While the pathophysiology of these adverse effects is not well understood, much recent research has focused on improving our ability to use available pharmacotherapy in the most effective and least toxic manner. Acute dystonic reactions only occur within the first days of antipsychotic treatment. They are often distressing and frightening for the patient and may even be dangerous. However, they can be effectively prevented or reversed with anticholinergics. Furthermore, the growing use of the new atypical antipsychotics will lead to a significant decrease in the rate of acute dystonic reactions. In contrast, tardive dystonia is a long-lasting menace in the course of antipsychotic treatment, for which there is no established therapy. Tardive dystonia is sometimes disabling or disfiguring and, like other tardive disorders, is potentially irreversible. Because, in most cases, patients need to continue taking the antipsychotic that has caused the adverse effect to prevent relapse of the mental illness, preventive measures are crucial. Antipsychotics should be prescribed only for patients affected by psychotic disorders, when definitely indicated and at the lowest effective dosage. The use of clozapine and other novel antipsychotic agents is also likely to represent an important step in the prevention and treatment of tardive dystonia. Compared with traditional antipsychotics, most of the new antipsychotics are characterised by a low acute extrapyramidal adverse effects liability and they also bring the hope of reducing the risk of tardive disorders. If tardive dystonia has occurred, switching to clozapine or another atypical antipsychotic and treatment with tetrabenazine, reserpine and botulinum toxin are possible options.

Episodic tardive dyskinesia and parkinsonism in bipolar disorder patients

Three cases of rapid cycling bipolar patients manifesting episodic parkinsonism are described. Moderate to severe parkinsonism and tardive dyskinesia appeared in all three of these patients before the onset of depression, then worsened during depression and disappeared during mania. A possible mechanism for this phenomenon is hypothesized.

Placebo response in refractory tardive akathisia

A double-blind, crossover drug trial with a patient with treatment-resistant tardive akathisia is described. The finding of a placebo response was unexpected, but emphasizes the value of such an approach in refractory cases.

Spontaneous improvement of tardive dystonia during mania

Two cases of bipolar affective disorder with tardive dystonic symptoms seemed to improve only with mood elevation, whether the latter occurred spontaneously or was 'induced' pharmacologically. Such cases could prove an interesting locus for the investigation of both affective disorders and tardive dyskinesias.