The Shanghai 800: prevalence of tardive dyskinesia in a Chinese psychiatric hospital

Tardive dyskinesia in Asia- current clinical practice and the role of neurologists in the care pathway

Tardive dyskinesia (TD) is a movement disorder that can arise as a side effect of treatment with dopamine receptor-blocking agents (DRBAs), including antipsychotic drugs (APDs) used to manage psychotic illnesses. Second-generation APDs (SGAs) are often preferred to first-generation drugs due to their lower propensity to cause TD, however many SGAs-treated patients still develop the condition. Although TD is a global health concern, evidence regarding the occurrence of TD and how it is managed in Asian countries is currently limited. This article reports the results of a systematic review of the published literature on TD focusing on its prevalence, types of patients, knowledge of the condition, causative factors, and usual treatment pathways in clinical practice in Asian countries. Epidemiological data suggest that the prevalence of TD is increasing globally due to an overall rise in APD use, contributing factors being polypharmacy with multiple APDs, the use of higher than necessary doses, and off-label use for non-psychotic indications. Although exact prevalence figures for TD in Asian countries are difficult to define, there is a similar pattern of rising APD use which will result in increasing numbers of TD patients in this region. These issues need to be addressed and strategies developed to minimize TD risk and manage this disabling condition which impacts patients' quality of life and daily functioning. To date, both research into TD has been predominantly psychiatry focused and the perspectives from neurologists regarding the clinical management of this challenging condition are scarce. However, neurologists have an essential role in managing the movement disorders manifestations that characterize TD. Optimum management of TD, therefore, should ideally involve collaboration between psychiatrists and neurologists in joint care pathways, wherever practical. Collaborative pathways are proposed in this article, and the challenges that will need to be addressed in Asian countries to improve the care of people with TD are highlighted, with a focus on the neurologist's viewpoint and the implications for the management of TD globally.

Tardive dyskinesia in Chinese patients with schizophrenia: Prevalence, clinical correlates and relationship with cognitive impairment

OBJECTIVE

Tardive dyskinesia (TD) has a high prevalence and is one of the distressing side effects of antipsychotic medications. Few studies have explored the relationship between TD, clinical correlates, and cognition. The aim of this study was to assess the prevalence, clinical correlates and cognitive impairment of co-occurring TD in Chinese patients with schizophrenia.

METHODS

We recruited 655 patients with chronic schizophrenia who met the DSM-IV diagnostic criteria for schizophrenia and collected clinical and demographic data. All patients were assessed using the Abnormal Involuntary Movement Scale (AIMS) for the severity of TD, Positive and Negative Syndrome Scale (PANSS) for psychopathological symptoms, and Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) for cognition.

RESULTS

The overall TD prevalence was 41.1%, 42.9% (246/574) in men and 28.4% (23/81) in women (χ2 = 6.1 df = 1, p < 0.05). There were significant differences in age, sex, duration of illness, number of hospitalizations, drug type, smoking and PANSS negative symptom subscore between TD and non-TD groups (all p < 0.05). Moreover, patients with TD scored lower for immediate memory, attention, delayed memory, and RBANS total scores (all p < 0.05). Logistic regression showed a significant correlation between TD and age, sex, drug type and attention subscore.

CONCLUSION

Our results suggest that multiple demographic and clinical variables may be associated with the development of TD. Moreover, TD patients may exhibit more cognitive impairment than non-TD patients.

Treatment of tardive dyskinesias with vitamin E*

The hypothesis that tardive dyskinesias observed after long-term administration of neuroleptics are due to the formation of free radicals following this medication has prompted studies on the use of vitamin E (α-tocopherol), an antioxidant to treat patients suffering from such side-effects. The present study aimed at reproducing earlier encouraging results in treating 23 patients with vitamin E, using a double-blind crossover design. Inclusion criteria were: duration of tardive dyskinesia for at least 3 months, appearance of the symptoms during neuroleptic treatment or after stopping this kind of medication. The 10 subjects in the first group (Gl) were treated for 14 days with 1 200 mg vitamin E per day and then for 14 days with placebo. For the second group (G2) with 9 subjects, the treatment periods were inversed. The 2 dropouts in each group were not due to experimental problems: there was no complication due to vitamin E intake, or only negligible side-effects. Side-effects were rated on the AIM scale on days 0, 14 and 28. The results of the present study do not confirm earlier reports: there was no significant difference in the therapeutic effect between placebo and vitamin E in any of the groups. However, the fact of taking these symptoms into account in the physician-patient relationship has contributed significantly to a decrease of tardive dyskinesia in both groups, from the beginning until the end of the investigation period, during which both neuroleptic and tranquilizing treatments were kept constant. Further studies should include longer treatment periods with vitamin E or even test the preventive effect of vitamin E in the production of tardive dyskinesia by neuroleptics.

Association between DBH 19bp insertion/deletion polymorphism and cognition in schizophrenia with and without tardive dyskinesia

Long-term antipsychotic treatment for schizophrenia is associated with the development of tardive dyskinesia (TD), which is involved in increased cognitive impairment. Dopamine beta-hydroxylase (DBH) gene associated with dopamine and norepinephrine systems influences cognition. Schizophrenia with TD have higher DBH activity than those without TD. This study examined whether DBH5'-insertion/deletion (-Ins/Del) polymorphism could influence cognitive function in schizophrenia with and without TD. The presence of DBH5'-Ins/Del polymorphism was determined in 345 schizophrenia with TD and 397 schizophrenia without TD. The Abnormal Involuntary Movement Scale and Repeatable Battery for Assessment of Neuropsychological Status (RBANS) were used to assess TD severity and cognition. The allele and genotype frequencies of DBH5'-Ins/Del polymorphism did not differ between patients with and without TD (both p>0.05). RBANS total score and subscales did not differ by DBH5'-Ins/Del genotype groups in patients with TD (all p>0.05). However, attention score significantly differed by DBH5'-Ins/Del genotype groups in those without TD (p<0.05). Patients without TD who were Del homozygous had significantly lower attention score than those without TD who were Ins alleles (p<0.05). Immediate memory and attention scores were lower in patients with TD than without TD (both p<0.05). This study indicated that DBH5'-Ins/Del polymorphism may not play a role in the susceptibility to TD and cognitive deficits in schizophrenia with TD, but it may influence cognitive function in schizophrenia with non-TD. Moreover, schizophrenia with TD experienced greater cognitive deficits than those with non-TD, especially in immediate memory and attention.

Antipsychotics-induced tardive syndrome: a retrospective epidemiological study

OBJECTIVES

Only little information of the epidemiology of tardive syndrome in patients using antipsychotics is available. Herein, we aimed to investigate the prevalence and risk factors of antipsychotics-induced tardive syndrome.

METHODS

This study was conducted by means of a retrospective survey. Subjects receiving antipsychotics for more than 6 months, but no other agents that may cause involuntary movements, were consecutively recruited. Tardive syndrome was evaluated in every included subject. Possible confounding medical conditions were carefully ruled out.

RESULTS

Of the 123 included subjects, 35 (28.5%) were found to have at least 1 episode of tardive syndrome. The prevalence of subtypes of tardive syndrome were as follows: tardive dyskinesia, 21.1%; tardive dystonia, 12.5%; tardive tremor, 2.4%; and tardive akathisia, 2.4%. Concurrent physical illness and a history of extrapyramidal symptoms were significant risk factors for tardive syndrome.

CONCLUSIONS

This study showed that antipsychotics may induce various types of tardive syndrome, of which tardive dyskinesia is the most predominant one. Physicians should be aware of this common and distressing adverse effect when using antipsychotics.

Gender differences in the prevalence, risk and clinical correlates of tardive dyskinesia in Chinese schizophrenia

OBJECTIVE

Despite extensive use of antipsychotic drug treatment, few studies address the prevalence of tardive dyskinesia (TD) in homogeneous ethnic groups such as the Chinese. This study examined gender-specific relationships between TD and symptom levels in schizophrenia among Han Chinese, which have previously received little systematic study.

MATERIALS AND METHODS

Five hundred and twenty-two inpatients with schizophrenia receiving long-term treatment with antipsychotics were evaluated with the AIMS. The patient's psychopathology was assessed with the Positive and Negative Syndrome Scale (PANSS). Demographic and clinical data were collected from a detailed questionnaire and medical records.

RESULTS

The overall TD prevalence was 33.7% with rates of 39.2% (138/352) in males and 22.4% (38/170) in females (chi (2) = 14.6, df = 1, p < 0.0001; adjust odds ratio 2.06; CI, 1.32-3.16). The AIMS score in patients with TD was lower in females than males (5.3 +/- 3.9 vs 6.7 +/- 3.7, t = 2.52, p < 0.01) after adjustment for the significant covariates. TD was associated with the negative symptoms on the PANSS in both genders, and with age, PANSS total and positive symptoms in men, not women.

CONCLUSION

Our present findings suggest that there are gender differences in the prevalence, risk, and clinical correlates of TD in schizophrenia. Although this study is limited by cross-sectional designs, the magnitude of these gender-specific differences is substantial and deservers further prospective study.

Tardive dyskinesia in Chinese inpatients with chronic schizophrenia

The objective of the study was to determine the point prevalence of tardive dyskinesia (TD) in Chinese inpatients with chronic schizophrenia and its association with sociodemographic, clinical and treatment variables and other movement disorders. A cross-sectional assessment of a randomly selected cohort of inpatients (n=225; mean age=42+/-7 years) with DSM-IV schizophrenia was employed using standard rating instruments for TD and other drug-induced movement disorders, in addition to catatonia, and psychotic, negative, depressive and obsessive-compulsive symptoms. Using Schooler and Kane's criteria, 15 subjects (6.7%) had TD. Patients with TD were significantly older and significantly fewer of them were taking antiparkinsonian medication than subjects without TD. There was no significant difference between the TD and non-TD groups with respect to other demographic, clinical and treatment variables including sex, age of onset, length of contact with psychiatric services, current antipsychotic dosage, negative symptoms, catatonia and parkinsonism. The results confirmed the low prevalence of TD in patients with chronic schizophrenia compared to those found in Caucasian patients. The study has also replicated the association of TD in Chinese schizophrenia patients with older age but failed to demonstrate any association between TD and other demographic or clinical characteristics including catatonia.

Tardive dyskinesia among Chinese and Malay patients with schizophrenia

The prevalence of tardive dyskinesia (TD) was studied with the Abnormal Involuntary Movements Scale in Chinese and Malay patients with schizophrenia who were hospitalized in a Singapore state psychiatric institute. We also studied the relationship of neuroleptic-induced extrapyramidal side effects to TD. By using established criteria, the rates of TD were 40.6% for Chinese and 29.0% for Malays, higher than previously reported for Chinese subjects. Older age and lower current neuroleptic dose were significantly associated with TD. Multivariate analysis, after controlling for other salient risk variables, did not show a significant difference in TD prevalence rates between the two races. We conclude that suggested differences in interethnic rates of TD among Chinese, Malays, and Westerners are unlikely to exist and that any variation in prevalence is more likely to be determined by differences in duration of exposure and dose levels of neuroleptic drugs.

Neuroleptic and anticholinergic drug use in Chinese patients with schizophrenia resident in a state psychiatric hospital in Singapore

OBJECTIVE

The objective of this study was to survey the prescribing pattern in Chinese patients with chronic schizophrenia in a state mental hospital in Singapore, and to compare our findings with those of surveys of Chinese patients in other countries.

METHOD

We surveyed the use of neuroleptic and anticholinergic agents among Chinese patients with chronic schizophrenia (n = 534) in a state mental hospital in Singapore.

RESULTS

Fifty-nine per cent of the patients received two or more neuroleptics (median daily dose of 400 mg chlorpromazine equivalents, range 50-2875 mg). There were no differences in gender distribution between those prescribed multiple neuroleptics as against an older group of those receiving none or only one neuroleptic medication. Sixty-six per cent of the patients were receiving depot neuroleptics, with more than half of these subjects also receiving additional oral neuroleptics. Patients who were prescribed multiple neuroleptics received significantly higher total doses than those receiving just one neuroleptic. Only 1% of patients were prescribed an atypical neuroleptic. Sixty-five per cent of patients were prescribed an anticholinergic agent. Those prescribed anticholinergic agents were younger, in receipt of higher doses of neuroleptic medications and had lower Simpson-Angus scores for extrapyramidal side-effects.

CONCLUSIONS

The pervasive use of multiple typical neuroleptics, marked underutilisation of atypical neuroleptics, and the lack of anticholinergic medication in patients who might benefit from such treatment are issues of substantial concern, warranting action in both psychiatry practice and mental health policy.

Gradual withdrawal of long-term anticholinergic antiparkinson medication in Chinese patients with chronic schizophrenia

Previous antiparkinson drug withdrawal studies involving white subjects have yielded inconclusive findings, whereas there is a paucity of data concerning Asian patients. A double-blind, placebo-controlled, randomized trial using gradual withdrawal of antiparkinson medication was conducted to evaluate the need for maintenance antiparkinson therapy for clinically stable Chinese patients with chronic schizophrenia. Seventy-five schizophrenic subjects who had received a diagnosis according to DSM-IV who had been ill for at least 5 years and on antipsychotic and antiparkinson medication for a minimum of 2 years entered the study. After baseline assessment, 58 subjects were matched according to age, sex, age at onset, length of illness, dose and length of antipsychotic and antiparkinson medication, and the presence of various extrapyramidal side effects. Randomly assigned dose-reduction and control groups were formed consisting of 29 subjects each. Trihexyphenidyl (THP), the only oral antiparkinson drug used in the study, was reduced by 1 mg every 2 weeks, whereas other psychotropic medication remained unchanged. Monthly assessment was performed using the Brief Psychiatric Rating Scale, Hamilton Rating Scale for Depression, Abnormal Involuntary Movement Scale, Simpson-Angus Scale, Barnes Akathisia Rating Scale, and the Nursing Observation Scale for Inpatient Evaluation-30. Complete withdrawal of THP was possible in 25 (90%) of the 28 subjects who completed the study, whereas considerable dose reduction was achieved in the remaining 3 subjects. There were no significant differences between dose reduction and control groups on any of the rating scales at the completion of the study. Our results suggest that long-term prophylactic administration of antiparkinson medication is unnecessary in the treatment of the majority of Chinese patients with chronic schizophrenia because withdrawal was accomplished without adverse mental or motor effects.

Transcultural psychopharmacology: present and future

Transcultural psychopharmacology is a field that seeks to determine whether differences exist in the pharmacokinetic and pharmacodynamic handling of psychotherapeutic drugs among various ethnic groups and, where present, to determine the reasons for such variation. During the past two decades a number of studies have reported differences in the pharmacokinetics and pharmacodynamics of psychotropic medications among various ethnic groups. These variations appear to be mainly determined by genetic predisposition but can be influenced by other factors such as environment, psychosocial supports, and physicians' prescribing habits. Due to study design limitations, many questions regarding the transcultural aspects of psychotropic medications still remain unanswered. This critical review discusses the transcultural psychopharmacology of Asian versus non-Asian populations. It will also include data on tardive dyskinesia, discuss new developments, touch on the problems associated with present research in the area, and provide recommendations for designing future research studies.

The fallacy of the medical model and the dangers of psychotropic drugs as a mode of treatment for mental disorders

With the decline of psychoanalytic thinking since the 50's and the 60's, mental disorders have been attributed to organic factors. This has been influenced by Social Darwinism, a belief in the survival of the fittest. The implication of such a philosophy is that social intervention is not the appropriate approach for the treatment of mental aberrations. The source of the problem lies within the individual. For example, schizophrenia has been attributed to brain anomalies, chemical imbalances or to the inheritance of genetic factors. To this day, in spite of the research efforts in that direction, the pursuit of these findings were proven to be illusive. Nevertheless, the search continues with a complete neglect of social factors. One problem is that writers disagreeing with this philosophy, find it difficult to publish their dissenting views. Since the source of the problem is within the individual, aberrations should be treated with drugs. However the efficacy of these drugs have not yet been confirmed and instead have been causing a lot of physical problems for patients. It is unfortunate that a number of influential clinical psychologists have adopted the medical model and are trying to obtain by legislation "prescription privileges" for psychologists. The author believes that this trend could be destructive to the profession of psychology, since it will weaken if not destroy the humanistic approach in the treatment of the mentally ill.

Usage and Side Effects of Neuroleptics in Elderly Japanese Patients

The authors assessed the use and side effects of neuroleptics (especially tardive dyskinesia [TD]) in elderly patients in Japan (N = 73; mean age 76 years, 32 men and 41 women) admitted for the first time to six psychiatric hospitals. The comparison group was 74 elderly patients with dementia admitted to nursing homes or psychiatric hospitals and not treated with neuroleptics. The mean dose of neuroleptics in the Japanese elderly patients was lower than that in Western countries; however, the prevalence of side effects was higher, possibly because of polypharmacy. The total number of psychotropic drugs correlated significantly with the number of side effects. Incidence of dyskinesia in the patients treated with neuroleptics (for a mean of 20 months) was significantly greater (44%) than that in non-neuroleptic-treated patients (14%). A significant risk factor for TD was long-term neuroleptic therapy, whereas age, gender, psychiatric diagnosis, neuroleptic dose, and antiparkinsonian drug use were not risk factors.

Tardive dyskinesia in non-western countries: a review

Tardive dyskinesia (TD) is a well-described adverse effect of treatment with neuroleptics. Studies from non-western countries are sparse and those that exist are not well publicized. We analyzed prevalence data on TD, published in English or French, and carried out in countries in Africa and Asia through December 1993. The estimated prevalence of TD among African subjects was 24% and among Asian subjects 17.2091. Both rates are in the middle range when compared with the western prevalence rates of 10-50%. Long-term hospitalization and older age were risk factors associated with TD. Female gender did not emerge as a risk factor. Also, several Asian studies showed that subjects with TD were taking lower doses of neuroleptics than subjects without TD. Prospective and controlled cross-cultural studies of TD are recommended for better understanding of associated risk factors and primary prevention.

New findings on tardive dyskinesia in a community sample

In a geographically defined area sample of 141 long-term psychiatric patients in day care in south London, the relationship between tardive dyskinesia (TD) and other aspects of illness, treatment, and social and psychological functioning were studied. The results are compared with previous findings. TD was significantly associated with parkinsonian symptoms and with the number of years in contact with the psychiatric services. There was a trend, in affective disorder only, towards an association with current neuroleptic dose. The patients with affective disorder also had higher rates of TD than patients with schizophrenia and paranoid psychosis. History of treatment with ECT correlated negatively with TD among those with schizophrenia, and positively among those with affective disorder. As in other studies, duration of neuroleptic treatment did not correlate with the presence or absence of TD. In contrast to some previous reports, age and cognitive status were not related to TD status. Possible reasons for this are discussed.

Cognitive dysfunction in schizophrenia followed up over 5 years, and its longitudinal relationship to the emergence of tardive dyskinesia

In this study, 51 chronic schizophrenic in-patients were evaluated for a range of demographic, clinical and medication variables, and followed up over five years. There was no significant overall change in cognitive function in this patient group as a whole, suggesting the absence of active disease at this stage of the illness. The only correlate of individual instances of cognitive deterioration over the study period was the emergence of new cases of tardive buccal-lingual-masticatory but not of limb-truncal dyskinesia, and the greater severity of such movement disorder. A positive family history was also identified prospectively as a predictor of the emergence of tardive dyskinesia in chronic schizophrenia.