Use Of First-generation Antipsychotics Research Articles

Metabolic consequences of second-generation antipsychotics in youth: appropriate monitoring and clinical management.

ObjectiveTo review the metabolic consequences of second-generation antipsychotics in youth and current monitoring and intervention guidelines for optimal treatment.BackgroundSecond-generation antipsychotics have largely replaced the use of first-generation antipsychotics in treating psychotic disorders in youth. In addition, there has been a dramatic increase in using these medications to treat a variety of nonpsychotic disorders. These medications have significant metabolic side effects, including weight gain. This raises concern, given the problem of pediatric obesity.Materials and methodsA review of current literature looking at prescribing practices and possible reasons for the increased use of second-generation antipsychotics in children and adolescents was conducted. Review of the mechanisms for why youth may be particularly vulnerable to the metabolic consequences (particularly weight gain) was similarly completed. In addition, data supporting the efficacy, rationale, and unique side-effect profile of each individual second-generation drug were evaluated to help inform providers on when and what to prescribe, along with current monitoring practices. The current evidence base for possible interventions regarding the management of antipsychotic-induced weight gain was also evaluated.Results and conclusionOn the basis of the literature review, there are several speculated reasons for the increase in prescriptions of second-generation antipsychotics. The choice of antipsychotic for youth should be based upon the disorder being treated along with the unique side-effect profile for the most commonly used second-generation antipsychotics. Monitoring strategies are also individualized to each antipsychotic. The current interventions recommended for antipsychotic-induced weight gain include lifestyle management, switching medication to a drug with a lower propensity for weight gain, and pharmacologic (particularly metformin) treatment.

Despite Expert Recommendations, Second-generation Antipsychotics Are Not Often Prescribed in the Emergency Department

BackgroundRecent expert guidelines recommend oral second-generation antipsychotics (SGAs) as first-line therapy for acute agitation in the emergency department (ED), with intramuscular (IM) SGAs as an alternative. However, little is known about how these meds are used in the ED or how often SGAs are prescribed. Objectives1) The measurement of patient characteristics, concomitant benzodiazepine use, and use of SGAs compared to haloperidol or droperidol; 2) the prescribing rates of SGAs over time in ED patients. MethodsThis is a structured analysis of a historical patient cohort from 2004–2011 in two university EDs. The cohort consisted of all patients receiving aripiprazole, olanzapine, quetiapine, risperidone, or ziprasidone. Descriptive analysis compared age, gender, use of first-generation antipsychotics (FGAs) such as haloperidol/droperidol, and rates of concomitant benzodiazepine use. Linear regression was used to test whether SGA prescribing increased over time. ResultsThere were 1680 unique patients accounting for 1779 ED visits who received SGAs over the study period, which is a minority of patients receiving any antipsychotic. Of patients receiving any SGA in the ED, most were given orally (93%). Adjunctive benzodiazepines were administered on 21% of visits, and were also administered on 21% of the visits involving alcohol + patients. The rate of SGA use in the ED is not increasing over time. ConclusionDespite expert recommendations, SGAs are administered a minority of the time to ED patients. The rate is not increasing over time. When used, SGAs are most commonly given orally, are often administered with benzodiazepines, and are frequently administered to alcohol-intoxicated patients.

Prevalence and Correlates of Cigarette Smoking among Chinese Schizophrenia Inpatients Receiving Antipsychotic Mono-Therapy

ObjectiveTo investigate the prevalence rate of cigarette smoking and its socio-demographic and clinical correlates in Chinese schizophrenia inpatients receiving antipsychotic mono-therapy.MethodsThis study was a cross-sectional, two-site, hospital-based survey. Four hundred and twenty-nine schizophrenia patients (male/female: 66.9% vs. 33.1%) were consecutively recruited from psychosis inpatient wards of two large specialty psychiatric hospitals in mainland China. Patients were assessed using a cigarette smoking questionnaire, the Positive and Negative Symptom Scale, the Simpson Angus Scale, the Barnes Akathisia Rating Scale, and the Abnormal Involuntary Movement Scale. Socio-demographic and other clinical data were also collected. We calculated the prevalence of current smoking in our sample as well as its indirectly standardized prevalence ratio (ISPR) using data from the 2010 Global Adult Tobacco Survey in China.ResultsThe prevalence rate of current smoking was 40.6% in our sample, and 57.5% in males and 6.3% in females. The ISPRs of all patients, men and women were 1.11(95%CI: 0.95∼1.29), 1.07(95%CI = 0.91∼1.24) and 4.64(95%CI = 2.12∼8.82), respectively. The overall and male-specific prevalence of current smoking did not differ significantly between patients and the general population. In multiple logistic regression analysis, male sex, older age, poor marital status, alcohol use, use of first-generation antipsychotics, longer duration of illness, more frequent hospitalizations, and more severe negative symptoms were independently associated with current smoking.ConclusionMale Chinese inpatients with schizophrenia who received a mono-therapy of antipsychotics were not more likely to smoke than the general population. Cigarette smoking is more common in schizophrenia patients with more severe illness.

A systematic review of metabolic side effects related to the use of antipsychotic drugs in dementia

In clinical practice, Second Generation Antipsychotics (SGAs) are often used as first-line treatment for the Behavioral and Psychological Symptoms of Dementia (BPSD) in older adults due to their fewer neurological adverse events and similar effectiveness compared with First Generation Antipsychotics (FGAs). SGAs, however, are associated with more severe metabolic side effects (weight gain, hyperglycemia, diabetes risk, and hyperlipidemia) than FGAs are. In general, older patients, especially those affected by dementia, are at increased risk for malnutrition, and tend to have lower basal metabolism and reduced liver and kidney function. However, little is known about the metabolic side effects of antipsychotic drugs in this population. A comprehensive review of the literature published between January 1996 and December 2012 investigating the metabolic side effects related to FGAs and SGAs use in old patients affected by dementia. Antipsychotic drugs currently used to treat BPSD in subjects with mild to moderate dementia are associated with weight gain. Currently, there are insufficient data to support a causal relationship between the use of FGAs and SGAs and changes in glucose homeostasis or lipid metabolism in older persons affected by severe dementia (MMSE <14). A possible association between antipsychotic drugs use and weight gain might exist, in particular in subjects with mild to moderate dementia whereas no significant effects are demonstrated regarding glucose homeostasis and lipid metabolism. The antipsychotic drugs potential for causing metabolic abnormalities in older patients requires further specifically designed studies. Clinicians must be aware of this possibility even if the shorter periods of treatment administered in late-life might not be as harmful as it is in younger individuals.

Trends in use of antipsychotics in elderly patients with dementia: Impact of national safety warnings

Based on evidence of an increased risk of death, drug agencies issued safety warnings about the use of second generation antipsychotics (SGAs) in the elderly with dementia. The French agency issued a warning in 2004. which was extended to all antipsychotics in 2008. Little is known about the impact of these warnings on use. We conducted a quasi-experimental study (interrupted time-series) in France, for 2003–2011, including subjects aged ≥65 with dementia and subjects aged ≥65 without dementia in the EGB database (1/97th representative random sample of claims from the main Health Insurance scheme). Outcomes were monthly rates of use of antipsychotics (by class and agent) and of five comparison drug classes (antidepressants, benzodiazepines, dermatologicals, antidiabetics, antiasthmatics). Trends were analyzed by joinpoint regression, impact of warnings by linear segmented regression. In patients with dementia (n=7169), there was a 40% reduction in antipsychotic use from 14.2% in 2003 to 10.2% in 2011. The reduction began before 2004 and was unaffected by the warnings. Use of first generation antipsychotics declined over the period, while use of SGAs increased and leveled off from 2007. Use of the five comparison drug classes increased on the period. In subjects without dementia (n=91,942), rates of overall antipsychotic use decreased from 2.3% in 2003 to 1.8% in 2011 with no effect of the warnings. Meanwhile, use of SGAs continuously increased from 0.37% to 0.64%. Antipsychotic use decreased in the elderly between 2003 and 2011, especially in dementia. The timing of the decrease, however, did not coincide with safety warnings.

Trends, correlates, and disease patterns of antipsychotic use among children and adolescents in Taiwan

We used Taiwan's population-based National Health Insurance database to investigate the trends, correlates, and disease patterns of antipsychotic use among children and adolescents. The National Health Research Institutes provided a database of 1,000,000 random subjects for study. We chose subjects who were aged 18years or younger during 1997-2005. In this sample, subjects who were given at least one antipsychotic prescription, including first-generation antipsychotics (FGAs) or second-generation antipsychotics (SGAs), were identified. Trends, prevalence, and associated factors of antipsychotic use were determined. The proportion of antipsychotic use for psychiatric and medical disorders was also analyzed. The 1-year prevalence of SGA use increased from 0.00% in 1997 to 0.09% in 2005, whereas the 1-year prevalence of FGA use ranged from 2.24 to 3.43% during this same period, with no significant change. Age and male gender were associated with higher SGA use. Among SGA users, the greatest proportion suffered from psychiatric disorders, including tics, hyperkinetic syndrome of childhood, schizophrenia, affective disorders, and autism. Among FGA users, a larger proportion was for medical conditions, including diseases of the digestive and respiratory systems. The prevalence of pediatric SGA use increased greatly from 1997 to 2005. Among pediatric subjects using antipsychotics, SGAs were mostly used for psychiatric disorders, whereas FGAs were mostly prescribed for medical conditions. Future research will focus on indication, dosage, frequency, duration, adverse effects, and off-label use of antipsychotics in the pediatric population.

Issues in the Management of Acute Agitation: How Much Current Guidelines Consider Safety?

Agitated behavior constitutes up to 10% of emergency psychiatric interventions. Pharmacological tranquilization is often used as a valid treatment for agitation but a strong evidence base does not underpin it. Available literature shows different recommendations, supported by research data, theoretical considerations, or clinical experience. Rapid tranquilization (RT) is mainly based on parenteral drug treatment and the few existing guidelines on this topic, when suggesting the use of first generation antipsychotics and benzodiazepines, include drugs with questionable tolerability profile such as chlorpromazine, haloperidol, midazolam, and lorazepam. In order to systematically evaluate safety concerns related to the adoption of such guidelines, we reviewed them independently from principal diagnosis while examining tolerability data for suggested treatments. There is a growing evidence about safety profile of second generation antipsychotics for RT but further controlled studies providing definitive data in this area are urgently needed.

Poster #227 LOCUS OF CONTROL AND SELF-ESTEEM IN PATIENTS AT THEIR FIRST PSYCHOTIC EPISODE

To assess the prevalence and correlates of antipsychotic polypharmacy (APP) across decades and regions.Electronic PubMed/Google Scholar search for studies reporting on APP, published from 1970 to 05/2009. Median rates and interquartile ranges (IQR) were calculated and compared using non-parametric tests. Demographic and clinical variables were tested as correlates of APP in bivariate and meta-regression analyses.Across 147 studies (1,418,163 participants, 82.9% diagnosed with schizophrenia [IQR = 42-100%]), the median APP rate was 19.6% (IQR = 12.9-35.0%). Most common combinations included first-generation antipsychotics (FGAs) + second-generation antipsychotics (SGAs) (42.4%, IQR = 0.0–71.4%) followed by FGAs + FGAs (19.6%, IQR = 0.0–100%) and SGAs + SGAs (1.8%, IQR = 0.0–28%). APP rates were not different between decades (1970–1979:28.8%, IQR = 7.5–44%; 1980–1989:17.6%, IQR = 10.8–38.2; 1990–1999:22.0%, IQR = 11–40; 2000–2009:19.2% IQR = 14.4–29.9, p = 0.78), but between regions, being higher in Asia and Europe than North America, and in Asia than Oceania (p < 0.001). APP increased numerically by 34% in North America from the 1980s 12.7%) to 2000s (17.0%) (p = 0.94) and decreased significantly by 65% from 1980 (55.5%) to 2000 (19.2%) in Asia (p = 0.03), with non-significant changes in Europe. APP was associated with inpatient status (p < 0.001), use of FGAs (p < 0.0001) and anticholinergics (< 0.001), schizophrenia (p = 0.01), less antidepressant use (p = 0.02), greater LAIs use (p = 0.04), shorter follow-up (p = 0.001) and cross-sectional vs. longitudinal study design (p = 0.03). In a meta-regression, inpatient status (p < 0.0001), FGA use (0.046), and schizophrenia diagnosis (p = 0.004) independently predicted APP (N = 66, R2 = 0.44, p < 0.0001).APP is common with different rates and time trends by region over the last four decades. APP is associated with greater anticholinergic requirement, shorter observation time, greater illness severity and lower antidepressant use.

Prescribing Trends in Bipolar Disorder: Cohort Study in the United Kingdom THIN Primary Care Database 1995–2009

ObjectivesTo determine changes in prescribing patterns in primary care of antipsychotic and mood stabiliser medication in a representative sample of patients with bipolar disorder in the United Kingdom over a fifteen year period and association with socio-demographic factors.MethodsWe identified 4700 patients in the Health Improvement Network (THIN) primary care database, who had received treatment for bipolar disorder between 1995 and 2009. The proportion of time for which each individual was prescribed a particular medication was studied, along with variation by sex, age and social depravation status (quintiles of Townsend scores). The number of drugs an individual was taking within a particular year was also examined.ResultsIn 1995, 40.6% of patients with bipolar disorder were prescribed a psychotropic medication at least twice. By 2009 this had increased to 78.5% of patients. Valproate registered with the greatest increase in use (22.7%) followed by olanzapine (15.7%) and quetiapine (9.9%). There were differences by age and sex; with young (18–30 year old) women having the biggest increase in proportion of time on medication. There were no differences by social deprivation status. By 2009, 34.2% of women of childbearing age were treated with valproate.ConclusionsLithium use overall remained relatively constant, whilst second generation antipsychotic and valproate use increased dramatically. Changes in prescribing practice preceded published trial evidence, especially with the use of second generation antipsychotics, perhaps with inferences being made from treatment of schizophrenia and use of first generation antipsychotics. Women of childbearing age were prescribed valproate frequently, against best advice.

The Pharmacoepidemiology of Antipsychotics for Adults with Schizophrenia in Canada, 2005 to 2009

To describe the frequency and trends in the use of antipsychotics for adults with schizophrenia in Canada from 2005 to 2009. Analyses were performed on IMS Brogan's Canadian Disease and Therapeutic Index (CDTI). The CDTI is a national physician panel study consisting of a representative sample of physicians both geographically and by specialty. Weighting adjustments are made to estimate national drug recommendations. Quarterly, panel physicians record all therapeutic recommendations during a 2-day period, including patient age, sex, and indication. Antipsychotic recommendations were estimated using CDTI data in which schizophrenia was listed as the indication. First-generation antipsychotic (FGA) recommendations for adults with schizophrenia increased by 38% between 2005 and 2009, from 329 380 to 454 960 recommendations. There were notable increases in recommendations for chlorpromazine, loxapine, zuclopenthixol, and flupentixol. Second-generation antipsychotic (SGA) recommendations increased to a much lesser extent (9%), which was mostly attributable to an increase in recommendations for clozapine. Drug recommendations for olanzapine decreased by 9%. The rate of increase of FGA use is now greater than that of SGAs. This may be due to data from recent comparative trials, which suggest that clinical efficacy, and the rate of neurological side effects is similar between FGAs and SGAs. The decreasing use of olanzapine may be due to metabolic adverse effects. The increased use of clozapine may be due to data on its superiority in patients who are treatment resistant.

Cigarette smoking in community-dwelling patients with schizophrenia in China

This study examined the prevalence of cigarette smoking and its socio-demographic and clinical characteristics in Chinese schizophrenia patients. A sample of 540 community-dwelling patients (female/male: 50.4% vs. 49.6%) with schizophrenia was interviewed using standardized assessment instruments. The patients’ basic socio-demographic and clinical data including smoking were collected. The prevalence of cigarette smoking was 28.5% in the whole sample, and 53.6% and 4.0% for men and women, respectively. In univariate analyses, male sex, use of first generation antipsychotics (FGAs) and alcohol consumption were significantly associated with smoking. In multiple logistic regression analysis, male sex, alcohol consumption, older age and lower level of education were independently associated with smoking. The prevalence of smoking in Chinese schizophrenia patients is considerably lower than most figures reported from Western settings. The dramatic differences between males and females underscore the influence of cultural norms on smoking.

Antipsychotic prescribing: old wine in new bottles?

Recent research suggests first generation antipsychotic medications may be no less effective or tolerated than second generation antipsychotics. To review prescribing practices in UK adolescent mental health settings. A review of literature and a postal survey (structured questionnaire) of clinicians in UK adolescent mental health settings (80 general and specialised in-patient units) were conducted. Second generation antipsychotics remain the drug of first choice for most UK clinicians (based on a survey response rate of 40%). Guidelines for antipsychotic use in adolescents need updating. Clinicians who qualified in the last 10 years may need specific training and experience in use of first generation antipsychotics.

The effect of ethnicity on prescribing practice and treatment outcome in inpatients suffering from schizophrenia in Greece

BackgroundNo studies have been conducted in Greece with the aim of investigating the influence of ethnicity on the prescribing and treatment outcome of voluntarily admitted inpatients. Most studies conducted in the UK and the US, both on inpatients and outpatients, focus on the dosage of antipsychotics for schizophrenic patients and many suffer from significant methodological limitations. Using a simple design, we aimed to assess negative ethnic bias in psychotropic medication prescribing by comparing discrepancies in use between native and non-native psychiatric inpatients. We also aimed to compare differences in treatment outcome between the two groups.MethodsIn this retrospective study, the prescribing of medication was compared between 90 Greek and 63 non-Greek inpatients which were consecutively admitted into the emergency department of a hospital covering Athens, the capital of Greece. Participants suferred from schizophrenia and other psychotic disorders. Overall, groups were compared with regard to 12 outcomes, six related to prescribing and six related to treatment outcome as assesed by standardised psychometric tools.ResultsNo difference between the two ethnic groups was found in terms of improvement in treatment as measured by GAF and BPRS-E. Polypharmacy, use of first generation antipsychotics, second generation antipsychotics and use of mood stabilizers were not found to be associated with ethnicity. However, non-Greeks were less likely to receive SSRIs-SNRIs and more likely to receive benzodiazepines.ConclusionsOur study found limited evidence for ethnic bias. The stronger indication for racial bias was found in benzodiazepine prescribing. We discuss alternative explanations and give arguments calling for future research that will focus on disorders other than schizophrenia and studying non-inpatient populations.

Pharmacokinetics of the Long‐Acting, First‐Generation Antipsychotic Fluphenazine

Despite the advantages of second‐generation antipsychotics, effectiveness trials and cost‐effective analyses have caused first‐generation antipsychotics to be reexamined with regard to place in therapy. Developing an understanding of all aspects of first‐generation antipsychotics, including the pharmacokinetic complexity of long‐acting decanoate formulations, are essential for practitioners in order to optimally manage both symptoms and adverse events. We describe a 55‐year‐old schizophrenic man with a severe movement disorder whose symptoms were mistaken for lithium toxicity. Further examination revealed that his fluphenazine plasma level was still detected 4 months after his last dose of fluphenazine decanoate had been administered. The incorrect diagnosis of lithium toxicity resulted in delayed treatment of his severe extrapyramidal symptoms. Administration of a routine dosage of benztropine titrated to 4 mg/day resolved his drug‐induced movement disorder within 72 hours. This case report demonstrates the persistent need for practitioners' awareness of the complex pharmacokinetic properties of long‐term fluphenazine decanoate treatment, resulting in prolonged absorption, and the continued importance of both recognizing adverse events resulting from dopamine D2‐receptor antagonism and developing the ability to distinguish between various types of movement disorders. The potential for increasing use of first‐generation antipsychotics highlights the need to revisit the nuances of long‐acting, injectable pharmacokinetics to improve patient outcomes.

The Use of First Generation versus Second Generation Antipsychotics as Add-on or as Switch Treatment and its Effect on QTc Interval: The Italian Experience in a Real-World Setting

Some psychotropic drugs are connected with prolongation of the QT interval, torsade de pointes and sudden death. Recent data suggest that with regard to this adverse effect, the atypical antipsychotic drugs are no safer than the older drugs. The purpose of this study is to evaluate the different use of first generation versus second generation antipsychotics as add-on (Group I) or switch treatment (Group II) and its effect on QTc interval in a sample of schizophrenic and bipolar inpatients without medical illness. All patients had been evaluated twice by using ECG: on admission and after two weeks of hospitalization. Exclusions criteria were: abnormalities in levels of potassium, magnesium and calcium, cardiovascular and metabolic diseases, alcohol or drug abuse. We found a significant (p < 0.01) greater use of first generation antipsychotic in Group I (73.80%) than in the Group II (33.33%). Also Group I showed a significant increase (p < 0.0001) in total chlorpromazine equivalent (476. 78 ± 448.80 mg/day vs 845.48 ± 491.64 mg/day) and in QTc interval (369.14 ± 33.75 ms vs 387.09 ± 31.97 ms), while we did not find any statistical difference in Group II during hospitalization. Our results, in spite of the small sample size, indicate that antipsychotic add-on can increase QTc interval more than switching to other antipsychotic in psychiatric patients without other risk factors.

Off-Label Use of Antipsychotic Medications in the Department of Veterans Affairs Health Care System

This study aimed to determine the prevalence of prescribing antipsychotics to adults without schizophrenia or bipolar disorder and to identify factors associated with such off-label use. Patients with at least one prescription for an antipsychotic medication from the Department of Veterans Affairs (VA) during fiscal year (FY) 2007 were identified in national VA administrative databases. Rates of off-label antipsychotic use were determined along with average doses. Multivariate logistic regression models identified sociodemographic and clinical characteristics associated with off-label use. Of the 279,778 individuals in FY 2007 who received an antipsychotic medication, 168,442 (60.2%) had no record of a diagnosis for which these drugs are approved. The most common mental illness diagnoses among patients given prescriptions for antipsychotics off label were posttraumatic stress disorder (PTSD, 41.8%), minor depression (39.5%), major depression (23.4%), and anxiety disorder (20.0%). Among VA patients with mental illness other than schizophrenia or bipolar disorder, the proportion who received prescriptions for antipsychotic medications ranged from a low of 9.1% among patients with adjustment reaction; to about 20% for those with depression, dementia, or PTSD; and to a high of 40.7% among patients with other psychoses. Doses were low, with over half of patients who received off-label quetiapine, risperidone, or first-generation antipsychotics receiving doses below those recommended for schizophrenia. In logistic regression models, patients diagnosed as having other psychosis or dementia had the highest odds of receiving an antipsychotic medication off label. Off-label use of antipsychotic medications was common. Given that these drugs are expensive, have potentially severe side effects, and have limited evidence supporting their effectiveness for off-label usage, they should be used with greater caution.

Tardive dyskinesia on clozapine treatment

Antipsychotic-induced tardive dyskinesia is a potentially irremediable and debilitating condition with the onset most commonly associated with the use of first-generation antipsychotics. (1) The development of tardive dyskinesia on clozapine, a second-generation antipsychotic, is uncommon, and the drug is therefore a treatment option for those patients who develop the syndrome following treatment with first-generation agents. I report on the case of a 27-year-old man who developed severe tardive dyskinesia following initiation of clozapine treatment. To the best of my knowledge, this is the first case of tardive dyskinesia associated with clozapine use reported in South Africa. Case presentation A 27-year-old single man was admitted to a psychiatric hospital for the first time in June 2006, with a diagnosis of substance-induced psychosis. He had a history of regular illicit polysubstance abuse from the age of 14 years (mostly cannabis and methaqualone (Mandrax) and methamphetamine (tik) abuse from 2005. He was discharged on chlorpromazine following his first hospital admission of 3 weeks after an initial unsuccessful trial of haloperidol. Although there was no history of continued substance abuse after his first hospital admission, he relapsed 6 months later and was re-admitted to hospital. The diagnosis was revised to schizophrenia. Clozapine was initiated and titrated up to 200 mg/day over a period of 2 weeks. His psychotic symptoms improved but depressive symptoms emerged, including dysphoria and suicidal ideation. Fluoxetine was commenced with good effect. Investigations, including a computed tomography (CT) head scan, full blood count, HIV ELISA test, thyroid function test and rapid plasma reagin (RPR) screen were done but the results were unremarkable. He was discharged after 4 months--euthymic, apsychotic and with no extrapyramidal features. He maintained regular community clinic reviews with good medication compliance and no evidence of ongoing substance abuse, and no adverse effects were reported. In March 2007, onset of orobuccal dyskinesia was noted. Fluoxetine was immediately stopped but he continued on clozapine 200 mg/daily. The dyskinesia progressively worsened over the following 4 months. In July 2007, he was re-admitted to hospital, overtly distressed by severe orofacial dyskinesia with involvement of the oesophagus, as well as upper-and lower-limb dyskinesia. His symptoms were incapacitating as he struggled to chew and swallow and he also complained of a re-emergence of suicidal thoughts, auditory hallucinations and feeling dysphoric. The severity of his dyskinesia was rated as 30 (severe) on the Abnormal Involuntary Movement Scale (AIMS). Apart from severe dyskinesia, his physical examination was unremarkable. Clozapine was stopped and regular oral diazepam was administered, with significant improvement of symptoms within days. Diazepam was thereafter substituted with a regular dose of clonazepam 1 mg twice daily. A repeat full blood count (FBC), HIV screen, thyroid screen, RPR, caeruloplasmin and antistreptolysin O titre (ASOT) were done. Results were within normal limits. A repeat CT head scan and an EEG were non-contributory. However, a SPECT scan showed left basal ganglia hypoperfusion, as well as decreased perfusion in the left thalamus, left parietal area and striatum. The abnormal limb movements improved after discontinuation of clozapine but he remained distressed by the ongoing orofacial dyskinesia. At the time of reporting, he had been on clonazepam for 7 weeks and a gradually increasing dosage of quetiapine. His AIMS score 8 weeks after stopping clozapine had improved to 19 (moderate) and, although the mood symptoms resolved, the psychosis had worsened. Discussion The atypical or second-generation antipsychotic agents (SGAs) are often drugs of choice in the treatment of psychotic illness, based on evidence of their reduced risk for associated acute extrapyramidal side-effects and tardive dyskinesia, compared with the first-generation antipsychotics (FGAs). …

Tardive dyskinesia on clozapine: A case report

Antipsychotic-induced tardive dyskinesia is a potentially irremediable and debilitating condition with the onset most commonly associated with the use of first-generation antipsychotics. The development of tardive dyskinesia on clozapine, a second-generation antipsychotic, is uncommon, and the drug is therefore a treatment option for those patients who develop the syndrome following treatment with first- generation agents. I report on the case of a 27-year-old man who developed severe tardive dyskinesia following initiation of clozapine treatment. To the best of my knowledge, this is the first case of tardive dyskinesia associated with clozapine use reported in South Africa.

Trends in Use of Antipsychotics and Mood Stabilizers Among Medicaid Beneficiaries With Bipolar Disorder, 2001-2004

Trends in Use of Antipsychotics and Mood Stabilizers Among Medicaid Beneficiaries With Bipolar Disorder, 2001-2004

P.3.c.030 Efficacy of atypicals comparing with clasical antipsychotics in first year treatment of first episode psychosis

To assess the prevalence and correlates of antipsychotic polypharmacy (APP) across decades and regions.Electronic PubMed/Google Scholar search for studies reporting on APP, published from 1970 to 05/2009. Median rates and interquartile ranges (IQR) were calculated and compared using non-parametric tests. Demographic and clinical variables were tested as correlates of APP in bivariate and meta-regression analyses.Across 147 studies (1,418,163 participants, 82.9% diagnosed with schizophrenia [IQR = 42-100%]), the median APP rate was 19.6% (IQR = 12.9-35.0%). Most common combinations included first-generation antipsychotics (FGAs) + second-generation antipsychotics (SGAs) (42.4%, IQR = 0.0–71.4%) followed by FGAs + FGAs (19.6%, IQR = 0.0–100%) and SGAs + SGAs (1.8%, IQR = 0.0–28%). APP rates were not different between decades (1970–1979:28.8%, IQR = 7.5–44%; 1980–1989:17.6%, IQR = 10.8–38.2; 1990–1999:22.0%, IQR = 11–40; 2000–2009:19.2% IQR = 14.4–29.9, p = 0.78), but between regions, being higher in Asia and Europe than North America, and in Asia than Oceania (p < 0.001). APP increased numerically by 34% in North America from the 1980s 12.7%) to 2000s (17.0%) (p = 0.94) and decreased significantly by 65% from 1980 (55.5%) to 2000 (19.2%) in Asia (p = 0.03), with non-significant changes in Europe. APP was associated with inpatient status (p < 0.001), use of FGAs (p < 0.0001) and anticholinergics (< 0.001), schizophrenia (p = 0.01), less antidepressant use (p = 0.02), greater LAIs use (p = 0.04), shorter follow-up (p = 0.001) and cross-sectional vs. longitudinal study design (p = 0.03). In a meta-regression, inpatient status (p < 0.0001), FGA use (0.046), and schizophrenia diagnosis (p = 0.004) independently predicted APP (N = 66, R2 = 0.44, p < 0.0001).APP is common with different rates and time trends by region over the last four decades. APP is associated with greater anticholinergic requirement, shorter observation time, greater illness severity and lower antidepressant use.