The effect of activation procedures on neuroleptic-induced akathisia

Dopamine D2 Receptor Occupancy Estimated From Plasma Concentrations of Four Different Antipsychotics and the Subjective Experience of Physical and Mental Well-Being in Schizophrenia: Results From the Randomized NeSSy Trial

BACKGROUND

Impaired subjective well-being in schizophrenia patients treated with antipsychotics has often been linked inter alia to the antidopaminergic effects of medication. Thus, it is important to capture the association between striatal dopamine D2 receptor occupancy (D2-RO) and global subjective well-being. We examined this association using data from our multicenter, randomized, double-blind Neuroleptic Strategy Study (NeSSy).

METHODS

An innovative double randomization process was used for allocation of patients to the specific treatment groups. Plasma drug concentrations were measured after 6 and 24 weeks of treatment to obtain the estimated D2-RO (eD2-RO) relative to literature values. We made an exploratory analysis of associations between eD2-RO and subjective well-being scores. One hundred two blood samples from 69 patients were available for the analysis. Because of the lack of a satisfactory occupancy model for quetiapine, only haloperidol, flupentixol, and olanzapine treatment groups were pooled, whereas aripiprazole data were analyzed separately, because of its partial agonistic properties.

RESULTS

In the pooled antagonist group, eD2-RO correlated negatively with the summarized well-being score. In a more detailed analysis, this association could be confirmed for all first-generation antipsychotic-treated patients, but not for the separate second-generation antipsychotic groups. In the aripiprazole group, higher eD2-RO was associated with impaired physical well-being, but had no association with mental well-being.

CONCLUSIONS

Our results suggest that high plasma levels and consequently high occupancy at D2 receptors are disadvantageous for subjective well-being, as distinct from the objective extrapyramidal side effects. To minimize patients' malaise, which disfavors adherence, implementation of therapeutic drug monitoring in the clinical routine may be useful.

Structured relaxation in the treatment of akathisia: case series

PURPOSE

Akathisia remains a common side effect especially from antipsychotic medication. If the condition is diagnosed the management options are limited. SUBJECTS/METHODOLOGY: We tested a structured relaxation program on nine patients with a diagnosis of schizophrenia suffering from akathisia. All patients were rated on Barnes Akathisia Scale (BAS) before the relaxation program, immediately after and again one week later.

RESULTS

The mean BAS score was before the relaxation 3.3 which reduced to 1.4 immediately after to finally 1.0 a week later. A Wilcoxon signed ranks test revealed a significant reduction in BAS score from baseline to endpoint (P = 0.026; Z = -2.232) and a highly significant reduction from baseline to follow-up (P = 0.008; Z = -2.636).

DISCUSSION

Although the study has a number of limitations the relaxation program appears to be a promising alternative to traditional treatment of akathisia. The patients appreciated the relaxation session but none of them managed to carry it out on their own without professional encouragement. The findings in this case series warrant further investigation with larger numbers of patients.

The Barnes Akathisia Rating Scale--revisited

Akathisia is a syndrome of motor restlessness, principally seen in association with antipsychotic medication. It is characterized by a subjective experience of mental unease and the urge to move, and manifests physically as particular patterns of restless movement. This review focuses on the signs and symptoms of the condition, and its diagnosis and assessment using the Barnes Akathisia Rating Scale. This scale was generated 15 years ago, and was derived from the findings of studies exploring the clinical features of antipsychotic-induced akathisia. Subsequently, its validity and reliability have been established, and it has been used extensively in clinical studies worldwide.

Fluoxetine dose-increment related akathisia in depression: implications for clinical care, recognition and management of selective serotonin reuptake inhibitor-induced akathisia

We report the case of a 22-year-old woman presenting major depressive episode with severe akathisia after an increase in fluoxetine. The patient developed severe restlessness and de novo suicidal ideation approximately 1 week after the dosage of fluoxetine was doubled, 1 year on from when the drug was first introduced. This case illustrates the importance of being alert to movement disorders in patients treated with selective serotonin reuptake inhibitors. The clinical implications are discussed. A management strategy based on the evidence in the existing literature is suggested.

A critical review of akathisia, and its possible association with suicidal behaviour

The purpose of this paper was to make a critical review of akathisia, based on the principles of evidence-based medicine, and to explore a possible link between akathisia and suicidal behaviour (suicidal thinking, parasuicide and completed suicide). An extensive systematic search was carried out on three major databases, Embase, ClinPsych and Medline. Fifty-seven relevant references were found, and a further 26 references were reviewed after careful selection from the references of the original references. The Cochrane Library did not contain any systematic reviews on the subject. Akathisia can be caused by several different groups of drugs, but most frequently by antipsychotics and to a lesser extent antidepressants. Research into akathisia is made considerably more difficult by the lack of a universally agreed definition of the condition. The underlying pathophysiology is still far from clear, but the literature offers guidelines on less hazardous management regimes for patients. On the basis of the existing literature, akathisia cannot at this stage unequivocally be linked to suicidal behaviour. It is certain, however, that the condition of akathisia does cause considerable distress in an already vulnerable group of patients. Because it is largely avoidable, new, more rigorous strategies must be put in place to prevent it. Copyright 2001 John Wiley & Sons, Ltd.