Akathisia: prevalence and associated dysphoria in an in-patient population with chronic schizophrenia

Drug Efficacy in the Treatment of Antipsychotic-Induced Akathisia: A Systematic Review and Network Meta-Analysis

Importance

Antipsychotic-induced akathisia (AIA) occurs in 14% to 35% of patients treated with antipsychotics and is associated with increased suicide and decreased adherence in patients with schizophrenia. However, no comprehensive review and network meta-analysis has been conducted to compare the efficacy of treatments for AIA.

Objective

To compare the efficacy associated with AIA treatments.

Data Sources

Three databases (MEDLINE, Web of Science, and Google Scholar) were systematically searched by multiple researchers for double-blind randomized clinical trials (RCTs) comparing active drugs for the treatment of AIA with placebo or another treatment between May 30 and June 18, 2023.

Study Selection

Selected studies were RCTs that compared adjunctive drugs for AIA vs placebo or adjunctive treatment in patients treated with antipsychotics fulfilling the criteria for akathisia, RCTs with sample size of 10 patients or more, only trials in which no additional drugs were administered during the study, and RCTs that used a validated akathisia score. Trials with missing data for the main outcome (akathisia score at the end points) were excluded.

Data Extraction and Synthesis

Data extraction and synthesis were performed, estimating standardized mean differences (SMDs) through pairwise and network meta-analysis with a random-effects model. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline was followed.

Main Outcomes and Measures

The primary outcome was the severity of akathisia measured by a validated scale at the last available end point.

Results

Fifteen trials involving 492 participants compared 10 treatments with placebo. Mirtazapine (15 mg/d for ≥5 days; SMD, -1.20; 95% CI, -1.83 to -0.58), biperiden (6 mg/d for ≥14 days; SMD, -1.01; 95% CI, -1.69 to -0.34), vitamin B6 (600-1200 mg/d for ≥5 days; SMD, -0.92; 95% CI, -1.57 to -0.26), trazodone (50 mg/d for ≥5 days; SMD, -0.84; 95% CI, -1.54 to -0.14), mianserin (15 mg/d for ≥5 days; SMD, -0.81; 95% CI, -1.44 to -0.19), and propranolol (20 mg/d for ≥6 days; SMD, -0.78; 95% CI, -1.35 to -0.22) were associated with greater efficacy than placebo, with low to moderate heterogeneity (I2 = 34.6%; 95% CI, 0.0%-71.1%). Cyproheptadine, clonazepam, zolmitriptan, and valproate did not yield significant effects. Eight trials were rated as having low risk of bias; 2, moderate risk; and 5, high risk. Sensitivity analyses generally confirmed the results for all drugs except for cyproheptadine and propranolol. No association between effect sizes and psychotic severity was found.

Conclusions and Relevance

In this systematic review and network meta-analysis, mirtazapine, biperiden, and vitamin B6 were associated with the greatest efficacy for AIA, with vitamin B6 having the best efficacy and tolerance profile. Trazodone, mianserin, and propranolol appeared as effective alternatives with slightly less favorable efficacy and tolerance profiles. These findings should assist prescribers in selecting an appropriate medication for treating AIA.

"Unvoluntary" Movement Disorders: Distinguishing between Tics, Akathisia, Restless Legs, and Stereotypies

Tics, stereotypies, akathisia, and restless legs fall at different places on the spectrum of discrete, unwanted and potentially disabling motor routines. Unlike tremor, chorea, myoclonus, or dystonia, this subgroup of abnormal movements is characterized by the subject's variable ability to inhibit or release undesired motor patterns on demand. Though it may be sometimes clinically challenging, it is crucial to distinguish these "unvoluntary" motor behaviors because secondary causes and management approaches differ substantially. To this end, physicians must consider the degree of repetitiveness of the movements, the existence of volitional control, and the association with sensory symptoms, or cognitive-ideational antecedent. This review aims to summarize the current existing knowledge on phenomenology, diagnosis, and treatment of tics, stereotypies, akathisia, and restless leg syndrome.

The effects of reserpine on depression: A systematic review

BACKGROUND

Reserpine is an effective antihypertensive drug, but its role in routine practice has declined such that it is rarely used. This is largely based on the assumption that reserpine causes depression. This assumption was a foundation for the original monoamine hypothesis of depression. However, there remains conflicting evidence as to whether reserpine causes depression, and no systematic review of available evidence.

AIMS

We systematically reviewed evidence on effects of reserpine on depressive and related symptoms (e.g. anxiety, suicidal ideation).

METHOD

Electronic searches of MEDLINE, Embase and PsycINFO were conducted to identify studies up to 14 February 2021. Studies of any methodological design involving reserpine-treated and reserpine-untreated conditions, in any adult human population, were included and a narrative synthesis of findings was undertaken. Risk of bias (RoB) was examined using ROBINS-I.

RESULTS

Of the 35 studies meeting inclusion criteria, 9 were randomised controlled trials. Eleven studies reported some depressogenic effects, 13 reported no effect and 11 reported putative antidepressant effects. Studies identifying depressive effects were more likely to examine people without psychiatric disorders at baseline, while studies identifying a potential antidepressant effect tended to treat fewer participants for shorter durations, at higher doses. Around one-third of studies conducted in people with psychiatric disorders showed beneficial effects on depression symptoms. 30/35 studies were at high RoB.

CONCLUSIONS

Associations between reserpine and depression are inconsistent and limited by a lack of high-quality evidence. Due to reserpine's apparently complex effects, we urge nuance rather than simplicity surrounding the monoamine hypothesis of depression.

Characterizing the sensorimotor domain in schizophrenia spectrum disorders

The rapidly evolving field of sensorimotor neuroscience reflects the scientific and clinical relevance of sensorimotor abnormalities as an intrinsic component of the disease process, e.g., in patients with schizophrenia spectrum disorders (SSD). Despite previous efforts, however, prevalence rates and relationships between different categories of sensorimotor abnormalities in SSD patients are still subject of ongoing debate. In this study, we examined five different categories of the sensorimotor domain (Neurological soft signs (NSS), parkinsonism, catatonia, akathisia, and tardive dyskinesia) according to well-established clinical ratings scales and the respective cut-off criteria in a sample of 131 SSD patients. We used a collection of statistical methods to better understand prevalence, overlap and heterogeneity, as well as psychopathological and cognitive correlates of sensorimotor abnormalities. 97.7% of the SSD patients considered by this study exhibited at least one categorically defined sensorimotor abnormality that tended to co-vary within three different sensorimotor subgroups (moderate, hyperkinetic and hypokinetic). Finally, hyperkinetic and hypokinetic groups differed significantly in their neurocognitive performance compared with the moderate group. The results suggest different patterns of clinical overlap, highlight the relationship between sensorimotor and cognitive domain and provide clues for further neurobiological studies.

Akathisia and Restless Legs Syndrome: Solving the Dopaminergic Paradox

Akathisia is an urgent need to move that is associated with treatment with dopamine receptor blocking agents (DRBAs) and with restless legs syndrome (RLS). The pathogenetic mechanism of akathisia has not been resolved. This article proposes that it involves an increased presynaptic dopaminergic transmission in the ventral striatum and concomitant strong activation of postsynaptic dopamine D₁ receptors, which form complexes (heteromers) with dopamine D₃ and adenosine A₁ receptors. It also proposes that in DRBA-induced akathisia, increased dopamine release depends on inactivation of autoreceptors, whereas in RLS it depends on a brain iron deficiency-induced down-regulation of striatal presynaptic A₁ receptors.

Diagnosis and treatment depression in schizophrenia

Depression is the third most common illness among patients with schizophrenia which negatively affects the course of the disease and significantly contributes to the mortality rate, due to increased suicide. Depression, along with negative symptoms and cognitive deficits, is one of the main factors that significantly decreases the quality of life and the disease prognosis in patients with schizophrenia. In addition, depression increases the frequency of exacerbations and readmissions, decreases the quality and duration of remissions and is associated with more frequent substance abuse and an increased economic burden. Data on the prevalence of depression among patients with schizophrenia are contradictory and are associated with a low detection rate of depression in such patients, a lack of clear diagnostic criteria and difficulties in differentiation between extrapyramidal and negative symptoms. The average prevalence of depression that meets the diagnostic criteria of major depressive episodes in patients with schizophrenia is 25% at a specific point, and 60% over the course of a lifetime; the frequency of subsyndromal depression is much higher. It is essential to distinguish between primary (axial syndrome) and secondary depressive symptoms (extrapyramidal symptoms, psychogenic or nosogenic reactions, social factors, etc.) to determine treatment strategies. The published data relating to randomized clinical trials for the development of evidence-based guidelines are limited. Current recommendations are based mainly on the results of small-scale trials and reviews. Certain atypical antipsychotics (quetiapine, lurasidone, amisulpride, aripiprazole, olanzapine, clozapine) are superior to typical antipsychotics in the reduction of depressive symptoms. Clozapine is effective in the management of patients at risk from suicide. The additional prescription of antidepressants, transcranial magnetic stimulation and electroconvulsive therapy are not always effective and are only possible following the management of acute psychosis in cases when antipsychotic monotherapy proved to be ineffective.

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

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

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.

Implications of Antipsychotic Use: Antipsychotic-Induced Movement Disorders, with a Focus on Tardive Dyskinesia

Antipsychotics can be life changing, but like all medications, they can also have unwanted effects, including drug-induced movement disorders such as tardive dyskinesia (TD). More patients are receiving antipsychotic treatment from non-psychiatry health care providers, including primary care and general practitioners. Despite misconceptions to the contrary, recent analyses suggest that the risk of drug-induced movement disorders such as TD has not been eliminated. Nurses across all care settings will increasingly encounter patients treated with antipsychotics. Nurses are critical for ensuring that patients exposed to antipsychotics receive screening and monitoring, care, and education.

Successful treatment of psychosis in dentatorubral-pallidoluysian atrophy with quetiapine: A case report

Introduction

Patients with dentatorubral‐pallidoluysian atrophy (DRPLA) sometimes elicit psychosis. First‐generation antipsychotic drugs have been reported to be effective in treating psychotic symptoms associated with the disease. However, little information is available on the benefits of second‐generation antipsychotic drugs (SGAs).

Case

We report on a 47‐year‐old man with DRPLA whose psychotic symptoms were effectively treated with quetiapine, one of the SGAs. He suffered from delusions, auditory hallucinations, and disorganized speech. Initially, other antipsychotic drugs were tried, but were withdrawn because of adverse effects before switching to quetiapine.

Conclusion

Our observations add to the notion that some of the SGAs are useful for ameliorating psychosis in DRPLA.

Successful Treatment with Olanzapine of Psychosis in Dentatorubral-pallidoluysian Atrophy: A Case Report

Patients with dentatorubral-pallidoluysian atrophy occasionally elicit psychosis. So far, one study reported first generation antipsychotics drugs may provide an effective treatment; however, there is no literature on the benefits of second generation antipsychotics. We report on a 44-year-old man with dentatorubral-pallidoluysian atrophy whose psychotic symptoms were effectively treated with olanzapine. Our observation suggests some second generation antipsychotics provide a therapeutic option for ameliorating psychosis in dentatorubral-pallidoluysian atrophy.

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.

Assessment of drug-related movement disorders in schizophrenia

Conventional antipsychotic drugs remain one of the mainstays of treatment of schizophrenia and related psychotic disorders. The therapeutic efficacy of these drugs is well established, both for treatment of acute symptoms and in relapse prevention. Unfortunately, they are associated with a broad range of side-effects, the most prominent of which is the development of a variety of movement disorders (see Box 1). Compared with the conventional antipsychotic agents, the newer, atypical antipsychotics have a lower liability for the acute extrapyramidal side-effects (EPS) and, for a few of the new drugs, there is some evidence of a lower risk of tardive dyskinesia (Barnes & McPhillips, 1999). Nevertheless, even with these newer agents, movement disorders are seen in a significant proportion of patients.

Revisiting Antipsychotic-induced Akathisia: Current Issues and Prospective Challenges

BACKGROUND

Akathisia continues to be a significant challenge in current neurological and psychiatric practice. Prompt and accurate detection is often difficult and there is a lack of consensus concerning the neurobiological basis of akathisia. No definitive treatment has been established for akathisia despite numerous preclinical and clinical studies.] Method: We reviewed antipsychotic-induced akathisia including its clinical presentation, proposed underlying pathophysiology, current and under investigation therapeutic strategies.

CONCLUSION

Despite the initial promise that second generation antipsychotics would be devoid of akathisia effects, this has not been confirmed. Currently, there are limited therapeutic options for the clinical practice and the evidence supporting the most widely used treatments (beta blockers, anticholinergic drugs) is still absent or inconsistent.

Akathisia: prevalence and risk factors in a community-dwelling sample of patients with schizophrenia. Results from the FACE-SZ dataset

The main objective of this study was to determine the prevalence of akathisia in a community-dwelling sample of patients with schizophrenia, and to determine the effects of treatments and the clinical variables associated with akathisia. 372 patients with schizophrenia or schizoaffective disorder were systematically included in the network of FondaMental Expert Center for Schizophrenia and assessed with validated scales. Akathisia was measured with the Barnes Akathisia Scale (BAS). Ongoing psychotropic treatment was recorded. The global prevalence of akathisia (as defined by a score of 2 or more on the global akathisia subscale of the BAS) in our sample was 18.5%. Patients who received antipsychotic polytherapy were at higher risk of akathisia and this result remained significant (adjusted odd ratio=2.04, p=.025) after controlling the influence of age, gender, level of education, level of psychotic symptoms, substance use comorbidities, current administration of antidepressant, anticholinergic drugs, benzodiazepines, and daily-administered antipsychotic dose. The combination of second-generation antipsychotics was associated with a 3-fold risk of akathisia compared to second-generation antipsychotics used in monotherapy. Our results indicate that antipsychotic polytherapy should be at best avoided and suggest that monotherapy should be recommended in cases of akathisia. Long-term administration of benzodiazepines or anticholinergic drugs does not seem to be advisable in cases of akathisia, given the potential side effects of these medications.

DRD2/ANKK1 Taq1A (rs 1800497 C>T) genotypes are associated with susceptibility to second generation antipsychotic-induced akathisia

Although the advent of atypical, second-generation antipsychotics (SGAs) has resulted in reduced likelihood of akathisia, this adverse effect remains a problem. It is known that extrapyramidal adverse effects are associated with increased drug occupancy of the dopamine 2 receptors (DRD2). The A1 allele of the DRD2/ANKK1, rs1800497, is associated with decreased striatal DRD2 density. The aim of this study was to identify whether the A1(T) allele of DRD2/ANKK1 was associated with akathisia (as measured by Barnes Akathisia Rating Scale) in a clinical sample of 234 patients who were treated with antipsychotic drugs. Definite akathisia (a score ≥ 2 in the global clinical assessment of akathisia) was significantly less common in subjects who were prescribed SGAs (16.8%) than those prescribed FGAs (47.6%), p < 0.0001. Overall, 24.1% of A1+ patients (A1A2/A1A1) who were treated with SGAs had akathisia, compared to 10.8% of A1- (thus, A2A2) patients. A1+ patients who were administered SGAs also had higher global clinical assessment of akathisia scores than the A1- subjects (p = 0.01). SGAs maintained their advantage over FGAs regarding akathisia, even in A1+ patients who were treated with SGAs. These results strongly suggested that A1+ variants of the DRD2/ANKK1 Taq1A allele do confer an associated risk for akathisia in patients who were treated with SGAs, and these variants may explain inconsistencies found across prior studies, when comparing FGAs and SGAs.

Effects of antipsychotic treatment on psychopathology and motor symptoms. A placebo-controlled study in healthy volunteers

RATIONALE

There is increased interest in elucidating the range of symptoms of schizophrenia and their response to treatment with medications. Particularly negative and cognitive symptoms are often resistant to the therapy with currently available antipsychotics. There are even similarities between negative symptoms in psychosis and the side effects of antidopaminergic antipsychotic drugs.

OBJECTIVES

The aim of this randomized, single-blinded, placebo-controlled study was to investigate the influence of a subchronic, prolonged neuroleptic-induced dopamine deficit on psychopathology and subjective well-being in healthy subjects.

METHODS

Seventy-two healthy volunteers without history of psychiatric diseases were included. A 7-day antidopaminergic intervention was provided with aripiprazole, haloperidol, and reserpine. For the clinical assessment, structured interviews and psychopathology and extrapyramidal symptom scales were used.

RESULTS

Seven out of 18 participants (38.9%) randomized to the haloperidol group terminated the study ahead of schedule. In the reserpine and the haloperidol group, significantly higher levels of negative and positive symptoms (PANSS scale) were documented. Depressive symptoms predominantly occurred in the reserpine group. Among all participants experiencing the antidopaminergic intervention, the subgroup with positive family history among first and second-generation relatives developed more pronounced depressive symptoms. Concerning extrapyramidal motor symptoms, the haloperidol group had significantly more severe manifestations than all three other groups.

CONCLUSION

Antidopaminergic modulation in healthy subjects induced substantial impairments in several domains of subjective well-being. In particular an association between hypodopaminergic states and depressive symptoms was observed which may be amplified by a genetic predisposition.

Dopamine sudden depletion as a model for mixed depression

Up to date research on Bipolar Disorders' phenomenology is in keeping with early descriptions made by E. Kraëpelin regarding the overlap in clinical presentation of both manic and depressive symptoms, namely, mixed states. The latter constitute a highly prevalent and characteristic clinical presentation of Bipolar Disorders' and entail therapeutic difficulties, prognostic implications and increased suicidal risk. Notwithstanding, mixed states', more specifically mixed depression, have been underestimated and bypassed to the point where currently neither diagnostic criteria nor specific therapeutic recommendations are provided. In addition to the lack of agreement on nosography and diagnostic criteria, mixed depression is usually excluded from Bipolar Disorders' neurobiological models. Furthermore, renewed interest in the role of dopamine in Bipolar Disorders' physiopathology has left aside hypothesis that may account for the aforementioned clinical presentation. Interestingly enough, other syndromes arising from sudden dopamine depletion such as neuroleptic dysphoria or withdrawal syndromes from dopaminergic drugs, bear remarkable clinical similarities with mixed depression. These syndromes have been subject of further research and may thus provide a model for mixed states' physiopathology. Indeed, this article accounts for clinical similarities between mixed depression, neuroleptic induced dysphoria, and other behavioural syndromes arising from sudden dopamine depletion. After reviewing neurochemical basis of such syndromes we present, to the best of our knowledge, the first neurobiological hypothesis for mixed depression. Specifically, such hypothesis regards over activation symptoms as auto regulatory attempts to compensate for sudden dopaminergic depletion. This hypothesis provides with a beginning step for the neglected problem of mixed depression, a non-antithetic link between the dopaminergic hypothesis for both manic and depressive symptoms, a plausible explanation regarding inter individual variability to mixed depression susceptibility, and suggests new approaches for the development of novel treatments in which dopamine dysregulation should be targeted.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Evaluation of akathisia in patients with schizophrenia, schizoaffective disorder, or bipolar I disorder: a post hoc analysis of pooled data from short- and long-term aripiprazole trials

The objective of this article is to assess the clinical characteristics of akathisia in patients with schizophrenia, schizoaffective disorder, or bipolar I disorder receiving aripiprazole, haloperidol, olanzapine, or placebo. We conducted post hoc analyses of pooled safety data from trials in patients with schizophrenia, schizoaffective disorder, and bipolar I disorder. Outcome measures included the incidence of akathisia, time to onset, duration, severity, and discontinuation due to akathisia, concomitant use of benzodiazepines and/or anticholinergics, Barnes Akathisia Rating Scale (BARS) scores, and the correlation between antipsychotic efficacy and akathisia. The results for schizophrenia and schizoaffective disorder were as follows: akathisia in 9% of aripiprazole- and 6% of placebo-treated patients; 12.5% of aripiprazole- versus 24% of haloperidol-treated patients; 11% of aripiprazole- versus 6% of olanzapine-treated patients. Bipolar I disorder: akathisia in 18% of aripiprazole- and 5% of placebo-treated patients. The clinical characteristics of akathisia were similar between each data set, regardless of disease. Akathisia was generally mild-to-moderate in severity. Discontinuation due to akathisia was low in both the schizophrenia trials (aripiprazole 0.3%; placebo 0%; aripiprazole 0.9%; haloperidol 2.3%; aripiprazole 1.2%; olanzapine 0.2%) and the bipolar trials (aripiprazole 2.3%; placebo 0%). Treatment-emergent akathisia was not associated with a poorer clinical response. In conclusion, akathisia with aripiprazole occurred early in treatment, was mild-to-moderate in severity, led to few study discontinuations, and did not compromise therapeutic efficacy.

Neuroleptic-induced movement disorders in a naturalistic schizophrenia population: diagnostic value of actometric movement patterns

Background

Neuroleptic-induced movement disorders (NIMDs) have overlapping co-morbidity. Earlier studies have described typical clinical movement patterns for individual NIMDs. This study aimed to identify specific movement patterns for each individual NIMD using actometry.

Methods

A naturalistic population of 99 schizophrenia inpatients using conventional antipsychotics and clozapine was evaluated. Subjects with NIMDs were categorized using the criteria for NIMD found in the Diagnostic and Statistical Manual for Mental Disorders – Fourth Edition (DSM-IV).

Two blinded raters evaluated the actometric-controlled rest activity data for activity periods, rhythmical activity, frequencies, and highest acceleration peaks. A simple subjective question was formulated to test patient-based evaluation of NIMD.

Results

The patterns of neuroleptic-induced akathisia (NIA) and pseudoakathisia (PsA) were identifiable in actometry with excellent inter-rater reliability. The answers to the subjective question about troubles with movements distinguished NIA patients from other patients rather well. Also actometry had rather good screening performances in distinguishing akathisia from other NIMD. Actometry was not able to reliably detect patterns of neuroleptic-induced parkinsonism and tardive dyskinesia.

Conclusion

The present study showed that pooled NIA and PsA patients had a different pattern in lower limb descriptive actometry than other patients in a non-selected sample. Careful questioning of patients is a useful method of diagnosing NIA in a clinical setting.

Relations between movement disorders and psychopathology under predominantly atypical antipsychotic treatment in adolescent patients with schizophrenia

OBJECTIVE

To examine relations between movement disorders (MD) and psychopathological symptoms in an adolescent population with schizophrenia under treatment with predominantly atypical antipsychotics.

METHOD

MD symptoms and psychopathology were cross-sectionally assessed in 93 patients (aged 19.6 +/- 2.2 years) using Tardive Dyskinesia Rating Scale (TDRS), Abnormal Involuntary Movement Scale (AIMS), Extrapyramidal Symptom Scale (EPS), Barnes Akathisia Scale (BAS), Brief Psychiatric Rating Scale (BPRS) and the Schedule for Assessment of Negative/Positive Symptoms (SANS/SAPS).

RESULTS

All patients with MD symptoms (n = 37; 39.8 %) showed pronounced global psychpathological signs (SANS/SAPS, BPRS: p = 0.026, p = 0.033, p = 0.001) with predominant anergia symptoms (p = 0.005) and inclinations toward higher anxiety- and depression-related symptoms (p = 0.051) as well as increased thought disturbance (p = 0.066). Both negative symptoms and anergia showed trends for positive correlations with tardive dyskinesia (p = 0.068; p = 0.065) as well as significant correlations with parkinsonism symptoms (p = 0.036; p = 0.023). Akathisia symptoms correlated significantly with hostile and suspicious symptoms (p = 0.013). A superfactor-analysis revealed four factors supporting the aforementioned results.

CONCLUSION

MD symptoms and psychopathology are in some respects related to each other. Motor symptoms representing on the one hand trait characteristics of schizophrenia might additionally be triggered by antipsychotics and finally co-occur with more residual symptoms within a long-term treatment.

Association of subjective cognitive dysfunction with akathisia in patients receiving stable doses of risperidone or haloperidol

BACKGROUND AND OBJECTIVE

Antipsychotic-induced akathisia leads to poor compliance with medication and is still a source of concern in the treatment with antipsychotic drugs. Regarding clinical characteristics, the distinguishing features of akathisia in comparison with other extrapyramidal syndromes are prominent subjective symptoms. The purpose of the present study was to examine the subjective cognitive dysfunction associated with antipsychotic-induced akathisia.

METHODS

Sixty-seven outpatients with schizophrenia receiving stable doses of risperidone or haloperidol were evaluated for akathisia and other extrapyramidal side effects. Subjective cognitive dysfunction was comprehensively assessed using the Frankfurt Complaint Questionnaire (FCQ). The severity of subjective cognitive deficits was compared between the groups with and without akathisia using analysis of covariance with relevant variables as covariates.

RESULTS

The akathisia group (n = 25) scored significantly higher on the total FCQ score than the non-akathisia group (n = 42) (P < 0.05). In phenomenological subscale scores, the akathisia group had significantly higher scores on various subscales, i.e. 'anxiety', 'disorder of selective attention', 'deterioration of discrimination', 'perceptual disorder' and 'disorder of coping responses' than the non-akathisia group (P < 0.05).

CONCLUSIONS

These results suggest that akathisia is significantly associated with a variety of subjective cognitive-perceptual deficits. Early therapeutic interventions for akathisia should be performed considering its significant association with the subjective cognitive dysfunction and the impairment of coping responses.

Anticholinergics for neuroleptic-induced acute akathisia

BACKGROUND

Neuroleptic-induced akathisia is one of the most common and distressing early-onset adverse effects of first generation 'typical' antipsychotic drugs. It is associated with poor compliance with treatment, and thus, ultimately, with an increased risk of relapse. We assessed the role of anticholinergic drugs as an adjunct therapy to standard antipsychotic medication in the pharmacological treatment of this adverse effect.

OBJECTIVES

To review anticholinergic drugs for neuroleptic-induced acute akathisia.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group's Register (October 1999), Biological Abstracts (1982-1999), CINAHL (1982-1999), Cochrane Library (Issue 4 1999), EMBASE (1980-1999), LILACS (1982-1999), MEDLINE (1966-1999) and PsycLIT (1974-1999). References of all identified studies were inspected for more trials and we contacted first authors. Each included study was sought as a citation on the Science Citation Index database. For this 2005-6 update, we searched the Cochrane Schizophrenia Group's Register (July 2005).

SELECTION CRITERIA

We included all randomised clinical trials of adjunctive anticholinergic drugs in addition to antipsychotic medication compared with placebo, for people with neuroleptic-induced acute akathisia.

DATA COLLECTION AND ANALYSIS

We quality assessed and extracted data independently. We calculated the fixed effects relative risk (RR), the 95% confidence intervals (CI) and, where appropriate, the number needed to treat (NNT) for homogeneous dichotomous data on an intention-to-treat basis. For continuous data, we calculated weighted mean differences (WMD).

MAIN RESULTS

We identified no relevant randomised controlled trials.

AUTHORS' CONCLUSIONS

At present, there is no reliable evidence to support or refute the use of anticholinergics for people suffering from neuroleptic-induced acute akathisia. Akathisia is a distressing movement disorder that remains highly prevalent in people with schizophrenia, both in the developed and developing world. This review highlights the need for well designed, conducted and reported clinical trials to address the claims of open studies as regards the effects of the anticholinergic group of drugs for akathisia.

Subjective experiences on antipsychotic medications: synthesis and conclusions

OBJECTIVE

This report synthesizes the literature describing the phenomenology, clinical importance and biology of subjective responses to antipsychotic medications in schizophrenia. A patient's experience of an antipsychotic is important because unpleasant or dysphoric responses can impair therapeutic relationships, lead to medication non-adherence, and have direct negative effects on a patient's quality of life.

METHOD

The author selectively reviewed early studies of subjective responses to antipsychotics and integrated this literature with the work of the other investigators in this special section.

RESULTS

There is substantial evidence that second-generation antipsychotics have advantages in causing fewer dysphoric responses when compared with first-generation agents. Clinical and neuroimaging studies suggest that dopamine blockade is an important determinant of many of these dysphorias. At this point in time it is unclear whether dysphoria results from extrapyramidal symptoms--particularly akathisia and akinesia--or whether they are a direct result of decreased dopamine activity.

CONCLUSION

Clinicians and researchers should continue to monitor dysphorias in schizophrenia. Contributions by the authors in this supplement provide new and more refined methods for measuring subjective responses in future studies.

Multidimensional sensory phenomena in antipsychotic-induced akathisia

The primary distinguishing features of akathisia in comparison with other extrapyramidal syndromes are the prominent subjective manifestations, which include various sensory symptoms. The sensory symptoms are multidimensional in nature and encompass various forms of bodily and mental sensations. The purpose of the present study was to elucidate the multidimensional aspects of the sensory phenomena associated with antipsychotic-induced akathisia. Seventy stable and chronic schizophrenic subjects receiving maintenance antipsychotic treatment were evaluated for akathisia and other extrapyramidal side effects. Subjective sensory phenomena were evaluated in 3 dimensions (ie, bodily sensations, mental sensations, and autonomic sensations). The frequency of each dimension of these sensory phenomena was compared between the groups with and without akathisia using chi test with Bonferroni correction. The akathisia group (n = 29) reported significantly more frequent focal or generalized bodily sensations than the non-akathisia group (n = 41) (P < 0.001). The akathisia group also showed significantly more frequent mental sensations such as mental urge and a feeling of inner tension/pressure (P < 0.001). In autonomic phenomena, there was a trend for the akathisia group to show more frequent autonomic sensations. The most common autonomic phenomena associated with akathisia were palpitation and difficulty breathing. The results of the present study suggest that the sensory phenomena of antipsychotic-induced akathisia are characterized by multidimensional features such as bodily sensations, mental sensations, and several autonomic sensations. The assessment of these multidimensional sensory phenomena would be useful in evaluating the important phenotypic features of akathisia.

Central action beta-blockers versus placebo for neuroleptic-induced acute akathisia

BACKGROUND

Neuroleptic-induced akathisia is a common, distressing early-onset adverse effect of neuroleptic drugs. It has been associated with poor treatment compliance and an increased risk of relapse.

OBJECTIVES

To determine the effects of central action beta-blockers compared with placebo for people with neuroleptic-induced acute akathisia.

SEARCH STRATEGY

We updated previous searches of the Cochrane Schizophrenia Group Register (May 1999), Biological Abstracts (January 1982-March 1999), The Cochrane Library (issue 3 1999), EMBASE (January 1980-March 1999), LILACS (January 1982-March 1999), MEDLINE (January 1964-March 1999), PsycLIT (January 1974-March 1999), and SCISEARCH by searching the Cochrane Schizophrenia Group Register (November 2003). We sought further references from published trials and their authors.

SELECTION CRITERIA

We included all randomised controlled clinical trials of central action beta-blockers versus placebo for people with neuroleptic-induced acute akathisia.

DATA COLLECTION AND ANALYSIS

Working independently, we selected and critically appraised studies, extracted data and analysed on an intention-to-treat basis. Where possible and appropriate we calculated risk ratios (RR) and their 95% confidence intervals (CI) with the number needed to treat (NNT). For continuous data we calculated Weighted Mean Differences (WMD).

MAIN RESULTS

We identified three randomised controlled trials (total n=51, maximum duration 72 hours). We were not able to draw any firm conclusions from such a small data set. In the two 48 hour studies no-one experienced full remission of akathisia, and only one person in each group experienced a 50% remission (n=11, 1 RCT, RR 1.04 CI 0.59 -1.83). One trial stated that no adverse effects occurred in the two groups (n=20, 1 RCT, RR not estimable). The 72 hour study did not show any statistical difference between the central acting beta-blocker (ICI 118,551) and placebo for the outcome 'no change/worse' (n=10, RR 0.22 CI 0.0 to 1.5).

REVIEWERS' CONCLUSIONS

There are insufficient data to recommend beta-blocking drugs for akathisia. These drugs are experimental for this problem, and this review highlights the need for more evaluative studies.

Neuroleptic dysphoria: towards a new synthesis

RATIONALE

Neuroleptic dysphoria (ND) is a subtle and under-recognized side effect of antipsychotic drugs. It is an all-inclusive descriptive phrase that encompasses a variety of unpleasant subjective changes in arousal, mood, thinking and motivation induced by neuroleptic drugs. Understanding this phenomenon has wide ranging clinical and research implications.

OBJECTIVE

The present review examined the themes identified in the original studies from the neuroleptic era in the light of recent findings from neuroimaging research, cumulative experience with second generation antipsychotic drugs, and new concepts such as pleasure responsivity, hedonic regulation and subjective tolerability.

METHODS

Empirical studies on neuroleptic drugs involving clinical populations treated for schizophrenia, Tourette's disorder and stuttering, studies performed on normal healthy volunteers and selected experimental studies in animals, are reviewed.

RESULTS

Dysphoric responses occur early during treatment and typically manifest as a dislike towards medication (drug aversiveness). Dysphoria persisting over time, may lead to adverse clinical consequences such as treatment non-adherence, substance abuse, poor clinical outcome, increased suicidality and compromised quality of life. Interference with the physiological processes of hedonic capacity by the neuroleptics due to their dopaminergic blocking action in the prefrontal cortex and the shell of nucleus accumbens is the putative mediating mechanism underlying the occurrence of dysphoric responses. Second generation antipsychotic drugs with an atypical receptor blocking profile are less likely to elicit dysphoric responses.

CONCLUSION

Viewing neuroleptic dysphoria within a broader spectrum of disorders of subjective tolerability and exploring its neurobiological mechanisms is relevant to addressing the nuances of antipsychotic therapy, and could help unravel the questions surrounding the pathophysiology of depression, substance abuse and other dysphoric clinical states.

Anticholinergics for neuroleptic-induced acute akathisia

BACKGROUND

Neuroleptic-induced akathisia is one of the most common and distressing early-onset adverse effects of conventional antipsychotic drugs, being associated with poor compliance with treatment, and thus, ultimately, with an increased risk of relapse. This review assesses the role of anticholinergic drugs as an adjunct to standard antipsychotic medication in the pharmacological treatment of this problem.

OBJECTIVES

To determine the clinical effects of anticholinergic drugs for neuroleptic-induced acute akathisia.

SEARCH STRATEGY

The reviewers undertook electronic searches of Biological Abstracts (1982-1999), CINAHL (1982-1999), Cochrane Library (Issue 4 1999), Cochrane Schizophrenia Group's Register (October 1999), EMBASE (1980-1999), LILACS (1982-1999), MEDLINE (1966-1999) and PsycLIT (1974-1999). References of all identified studies were inspected for more trials and first authors contacted. Each included study was sought as a citation on the Science Citation Index database.

SELECTION CRITERIA

All randomised clinical trials of anticholinergic drugs versus placebo for people with neuroleptic-induced acute akathisia.

DATA COLLECTION AND ANALYSIS

Two reviewers, working independently, selected, quality assessed and extracted data. These data were then analysed on an intention-to-treat basis. For homogeneous dichotomous data the fixed effects relative risk (RR), the 95% confidence intervals (CI) and, where appropriate, the number needed to treat (NNT) were calculated on an intention-to-treat basis. For continuous data, reviewers calculated weighted mean differences.

MAIN RESULTS

No randomised controlled trials could be included.

REVIEWER'S CONCLUSIONS

At present, there is no reliable evidence to support or refute the use of anticholinergics for people suffering from neuroleptic-induced acute akathisia. Akathisia is a most distressing movement disorder that remains highly prevalent, both in the developed and developing world. This review highlights the need for well designed, conducted and reported clinical trials to address the claims of open studies as regards the effects of the anticholinergic group of drugs for akathisia.

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.

Prevalence and Characteristics of Subjective Akathisia, Objective Akathisia, and Mixed Akathisia in Chronic Schizophrenic Subjects

Akathisia is a complex syndrome that is characterized by subjective inner restlessness and objective motor manifestations, and it can be classified into several subtypes. The purpose of this study was to examine the prevalence of subjective akathisia, objective akathisia, and mixed akathisia, and to evaluate their relationships with other drug-induced movement disorders, in chronic schizophrenic subjects treated with antipsychotics. One hundred and forty-two in-patients were assessed for akathisia, drug-induced parkinsonism, and tardive dyskinesia. The subtypes of akathisia were specified according to the Barnes Akathisia Rating Scale. Drug-induced parkinsonism and tardive dyskinesia were assessed using the Simpson-Angus Scale and the Abnormal Involuntary Movement Scale, respectively. The prevalence of subjective, objective, and mixed akathisia was 11.3%, 6.3%, and 16.9%, respectively. Regarding concurrence rates of akathisia subtypes and other extrapyramidal syndromes, the comorbidity rates of mixed akathisia with parkinsonism and tardive dyskinesia were higher. In conclusion, the present study presented the prevalence of subjective, objective, and mixed akathisia among hospitalized schizophrenic subjects. Mixed akathisia showed an association with parkinsonism and tardive dyskinesia, suggesting a common vulnerability involved in these drug-induced movement disorders. Further studies are required to elucidate more detailed clinical characteristics of each subtype of akathisia.

Treatment of neuroleptic-induced akathisia with the 5-HT2A antagonist trazodone

Akathisia is a common and distressful extrapyramidal adverse side effect usually resulting from the use of antipsychotic medications. Early management of akathisia is important because it may be associated with poor treatment response and medication noncompliance. Unfortunately many patients fail to respond to standard management of akathisia. In addition to dopaminergic mechanisms, it has been hypothesized that serotonin may play a prominent role in the pathophysiology of akathisia. Trazodone is an antidepressant agent demonstrating prominent serotonergic antagonistic properties. This open-label pilot study investigates the efficacy of trazodone in the management of akathisia. Nine female patients with a score of at least "mild akathisia" on the Barnes Akathisia Scale, and receiving a stable dose of antipsychotic medication, were administered trazodone, titrated up to a dosage of 100 mg/day over a period of 5 days. The patients demonstrated marked improvement in symptoms of akathisia. In addition, some improvement was noted in symptomatology of anxiety, depression, and psychosis. These observations suggest the use of trazodone as a beneficial and relatively safe medication for the treatment of antipsychotic medication-induced akathisia. Further study in the context of a double-blind, placebo-controlled trial is mandated to substantiate these preliminary findings.

Clinical characteristics and associated factors in antipsychotic-induced akathisia of Asian patients with schizophrenia

OBJECTIVE

We studied the prevalence of akathisia and its relationship to a number of sociodemographic and clinical factors in a population of Chinese inpatients with Schizophrenia.

METHOD

Six-hundred and forty-five patients were recruited for the study. Akathisia was assessed using the Barnes Akathisia Rating Scale (BARS), dyskinesia by the Abnormal Involuntary Movement Scale (AIMS) and extrapyramidal side effects (EPSE) were assessed by the Simpson-Angus Rating Scale (SARS).

RESULTS

Only 35 (5%) patients were assessed to have akathisia. There was no gender or ethnic difference in the rates of akathisia. However, the majority of the patients (65%) were receiving an anticholinergic agent at the time of the study.

CONCLUSION

Our findings of an overlap between TD and EPSE support the suggestion that there may be a common vulnerability for these movement disorders. The finding of a low rate of akathisia among our Asian patients suggests an inter-ethnic difference in the vulnerability for the development of akathisia. However, comparing our results with the rates reported from other countries may be hampered by the diagnostic and methodological differences across studies.

Postpsychotic depression in schizophrenia patients

Depression is a frequent comorbidity in the course of schizophrenia and is associated with increased mortality from suicide. Postpsychotic depression is defined as the syndrome of major depression occurring following remission of psychotic symptoms in a person with schizophrenia. Various proposed causes, differential diagnosis, and issues regarding management of postpsychotic depression are discussed.

Benzodiazepines for neuroleptic-induced acute akathisia

BACKGROUND

Neuroleptic-induced akathisia is one of the most common and distressing early-onset adverse effects of antipsychotic drugs, being associated with poor compliance with treatment, and thus, ultimately, to an increase risk of relapse. This review assesses the role of benzodiazepines in the pharmacological treatment of this problem.

OBJECTIVES

To determine the effects of benzodiazepines versus placebo for people with neuroleptic-induced acute akathisia.

SEARCH STRATEGY

Biological Abstracts (January 1982-March 1999), The Cochrane Library (Issue 3 1999), The Cochrane Schizophrenia Group's Register (May 2001), EMBASE (January 1980-March 1999), LILACS (January 1982-March 1999), MEDLINE (January 1964-March 1999), PsycLIT (January 1974-March 1999), and SCISEARCH were searched. Further references were sought from published trials and their authors.

SELECTION CRITERIA

All randomised clinical trials comparing benzodiazepines with placebo for people with antipsychotic-induced acute akathisia.

DATA COLLECTION AND ANALYSIS

Two reviewers, working independently, selected, quality assessed and extracted data. These data were then analysed on an intention-to-treat basis. For homogeneous dichotomous data the fixed effects relative risk (RR), the 95% confidence intervals (CI) and, where appropriate, the number needed to treat (NNT) were calculated on an intention-to-treat basis. For continuous data, reviewers calculated weighted mean differences.

MAIN RESULTS

Two small (total N=27) randomised controlled trials were included. By seven to 14 days, there was a reduction in symptoms for those patients receiving clonazepam compared with placebo (2 RCTs, N=26, RR 0.09 CI 0.01 to 0.6, NNT 1.2 CI 0.9 to 1.5). No significant difference was found for adverse events (2 RCTs, N=26, RR 3.00 CI 0.2 to 62) or the need for anticholinergic medication (2 RCTs, N=26, RR 1.56 CI 0.9 to 2.7). No one left the two studies early. Data on mental, social and family outcomes could not be pooled and there was little or no data on user satisfaction, deaths, violence, criminal behaviour and costs.

REVIEWER'S CONCLUSIONS

Over a short follow-up period, the use of benzodiazepines may reduce the symptoms of antipsychotic-induced acute akathisia. This review highlights the need for well designed, conducted and reported clinical trials to address the claims of open studies.

Suicide and schizophrenia

Suicide and suicide attempts occur at a significantly greater rate in schizophrenia than in the general population. Common estimates are that 10% of people with schizophrenia will eventually have a completed suicide, and that attempts are made at two to five times that rate. Demographically associated with suicidality in schizophrenia are being young, being early in the course of the illness, being male, coming from a high socioeconomic family background, having high intelligence, having high expectations, not being married, lacking social supports, having awareness of symptoms, and being recently discharged from the hospital. Also associated are reduced self-esteem, stigma, recent loss or stress, hopelessness, isolation, treatment non-compliance and substance abuse. Clinically, the most common correlates of suicidality in schizophrenia are depressive symptoms and the depressive syndrome, although severe psychotic and panic-like symptoms may contribute as well. This review specifically explores the issue of depression in schizophrenia, in relation to suicide, by organizing the differential diagnosis of this state and highlighting their potentially treatable or correctable causes. This differential diagnosis includes both acute and chronic disappointment reactions, the prodrome of an acute psychotic episode, neuroleptic induced akinesia and akathisia, the possibility of direct neuroleptic-induced depression, negative symptoms of schizophrenia, and the possible co-occurrence of an independent depressive diathesis. The potential beneficial roles of 'atypical' antipsychotic agents, including both clozapine and more novel agents, and adjunctive treatment with other psychopharmacological medications are considered, and the important roles of psychosocial factors and interventions are recognized.

Depressive symptoms in stable chronic schizophrenia: prevalence and relationship to psychopathology and treatment

The prevalence and correlates of the depressive syndrome were explored in a population of 120 patients with stable, chronic schizophrenia living in the community. The presence of clinically significant depressive symptoms was defined by a score of 17 or greater on the Beck Depression Inventory. Patients were examined to assess severity of schizophrenic symptoms and medication side-effects. Sixteen of the 120 patients (13.3%) had significant depressive symptoms. Depressive symptoms were significantly correlated with the hostility/suspiciousness (P<0.0001), the positive symptom (P=0.0009) factor of the BPRS and with scores on the Significant Others Scale, a measure of patients' perceived lack of social support (P=0.0004). The association between depression and akathisia approached significance (P=0.007). There was no correlation with demographic variables, alcohol intake, antipsychotic dosage or anticholinergic dosage. Using a scale that rates the subjective aspects of the depressive syndrome, we found no evidence of a relationship between depression and negative symptoms in this population. These results indicate that persistent depressive symptoms in stable patients in the community are related to the degree of persistent positive psychotic symptoms, patient perceptions of social support and, weakly, to the degree of akathisia but not other aspects of antipsychotic treatment.

Prevalence and characteristics of patients with pseudoakathisia

Pseudoakathisia (PsA) is characterised by the typical motor features of akathisia but there is a lack of subjective awareness. A total of 153 in-patients on neuroleptic medication hospitalized in two representative wards of the Psychiatric Hospital of Attica in Athens were rated on the census date using the Rating Scale for Drug-Induced Akathisia [Barnes, Br. J. Psychiatry, 154 (1989) 672-676], the Rating Scale for Extrapyramidal Side-Effects [Simpson and Angus, Acta Psychiatr. Scand. 212 (Suppl.) (1970) 11-19] and the Abnormal Involuntary Movements Scale [US Department of Health, Education and Welfare, ECDEU Assessment Manual (1976) pp. 534-537]. Eight subjects of the total in-patient population were found to have PsA of chronic type (point prevalence 5.23%). The point-prevalence of PsA among schizophrenic patients was 4.76%. In addition to the diagnosis of chronic pseudoakathisia, five patients (62.5%) had a concurrent diagnosis of chronic parkinsonism. Among patients with PsA, significant correlations were found between parkinsonism score and current daily dose of neuroleptics or high potency neuroleptics. There is evidence of a relationship between chronic pseudoakathisia, chronic parkinsonism and daily dose of neuroleptic.

Extrapyramidal symptoms and residual psychopathology with low-dose neuroleptics

Residual psychopathology associated with EPS has been mainly assessed in experimental studies where neuroleptics were administered at standard, fixed dosages. The present study evaluates residual psychopathology in 69 schizophrenic patients treated with moderate, flexible doses of neuroleptics (430 mg eq. CPZ) at the out-patient Community Mental Health Services (CMHSs) in Bologna. Akathisia was present in 27.5 per cent of patients and parkinsonism in 27.5 per cent. A more severe psychopathological state was associated with both side-effects, as seen by significantly higher BPRS global scores. This severity was due to tension and anxiety-depression symptoms in patients with akathisia and to negative symptomatology in patients with parkinsonism, as shown by significant associations with BPRS subscales ANS-DEP and NEG, respectively. In conclusion, the present study underlines that EPS are frequent even in an out-patient setting where moderate neuroleptic doses are employed, and more importantly shows that in these conditions, the residual psychopathology resulting from EPS is clinically very significant. Copyright 2000 John Wiley & Sons, Ltd.

Pseudoakathisia: a review and two case reports

Pseudoakathisia is a movement disorder associated with the use of neuroleptic medication. There has been disagreement on the precise nature of the condition and its relation to akathisia. The available literature on pseudoakathisia is reviewed. Two cases of pseudoakathisia are reported that demonstrate the reversibility of the diagnosis of pseudoakathisia.

Does akathisia influence psychopathology in psychotic patients treated with clozapine?

BACKGROUND

Akathisia has been reported to predict more severe symptoms and poorer treatment response to typical neuroleptics among patients with schizophrenia. Akathisia has also been associated with symptom exacerbation. This study addressed four questions: 1) Does akathisia predict greater severity in global psychopathology? 2) Is this effect global or specific? 3) Does clozapine treatment alter this relationship? 4) Does severity of psychopathology covary with the level of akathisia?

METHODS

Akathisia and clinical symptoms were examined in 33 "treatment refractory" schizophrenic patients treated with clozapine across 16 weeks. Weekly ratings were Barnes Akathisia Rating Scale, Abbreviated Dyskinesia Rating Scale, and Brief Psychiatric Rating Scale (BPRS). Patients were classified as "with" (n = 15) or "without" (n = 18) akathisia. Data analyses involved independent t-test comparisons of selected variables, between-group multivariate analyses of variance across time for BPRS Total scores and Guy's five factors, and partial correlations to assess covariation between BPRS scores and level of akathisia.

RESULTS

Akathisia predicted more severe global psychopathology, specific to the Activation (AC) and Thought Disturbance (TH) factors. These relationships did not change with clozapine treatment even when akathisia declined. Interestingly, level of akathisia did not covary with severity of psychopathology.

CONCLUSIONS

In this sample, akathisia predicted more severe psychopathology, specific to AC and TH BPRS factor scores. Clozapine treatment did not alter this relationship. Although the presence of akathisia predicted more severe symptoms, the level of akathisia did not covary across time with severity of psychopathology, suggesting an "uncoupling" of these symptom domains.

Treatment of neuroleptic-induced akathisia with the 5-HT2 antagonist mianserin. Double-blind, placebo-controlled study

BACKGROUND

Serotonin (5-HT):dopamine imbalance may underlie neuroleptic-induced akathisia.

AIM

To evaluate the efficacy of the 5-HT2 antagonist, mianserin in neuroleptic-induced akathisia.

METHODS

Thirty neuroleptic-treated patients with schizophrenia were randomly allocated in a double-blind design to receive either mianserin (15 mg/day) or placebo for five days. Patients were assessed at baseline and on Days 3 and 5 by the Barnes Akathisia Scale (BARS), as well as by other relevant clinical rating scales.

RESULTS

Compared with the placebo group, the mianserin-treated patients showed a significant reduction in all four BARS subscales by Day 5, with mean reductions in the BARS global score of 9.9% and 52.2%, respectively (P = 0.006). Response to treatment (a reduction of at least two points on the BARS global subscale), was noted in six patients (40%) in the mianserin group and only one patient (9.1%) in the placebo group (P = 0.04, log odds ratio 2.23).

CONCLUSIONS

Mianserin at a low dose may be a promising therapeutic option for patients with acute neuroleptic-induced akathisia.

The antipsychotics. A pediatric perspective

As can be discerned from this article, antipsychotics are commonly prescribed, and they are not used to treat only psychosis. Although some data support the use of typical antipsychotics in pediatric patients with a variety of psychiatric syndromes, concerns about the safety and tolerability of these agents often complicated their use and probably even interfered with case identification. A fundamentally new group of medications, the atypicals, have now become available and may not only have improved tolerability but also may have greater ability to reduce some target symptoms. Because of their superior side-effect profile in adults, some of these atypical treatments probably will be commonly prescribed despite a relative paucity of data about their use in the young. Moreover, although frequently prescribed in this age group, the overall prescription rate for antipsychotics will probably increase because of the putative improved safety profile of the newer agents. However, it is possible that serious side effects, such as tardive dyskinesia or neuroleptic malignant syndrome, may occur with these atypical agents. For this reason, the enthusiasm for prescribing these newer treatments should be tempered with the understanding that these agents, although they may in some ways be superior to their predecessors, still possess the potential for significant adverse events. Four atypical antipsychotics are currently marketed in the United States (see Table 2). One additional agent, ziprasodone, is undergoing clinical investigation. Ziprasodone has been shown to be superior to placebo in adults suffering from schizophrenia. Ziprasodone will probably be marketed in the United States in the near future. Whether all of these atypical drugs will have a place in the clinical armamentarium of the pediatric psychopharmacologist remains to be determined. Because the receptor binding profile of the atypical agents differ, it is not possible to assume that what is true for one of these agents is true for the others. Although results from most preliminary studies with atypical antipsychotics indicate that these are promising agents for pediatric patients, further research is needed to define just how these medications may be most judiciously used.