Assessing and monitoring antipsychotic-induced movement disorders in hospitalized patients: a cautionary study.

OBJECTIVE: To assess the amount of documentation and level of assessment provided by attending physicians and nursing staff in regard to extrapyramidal symptoms (EPS) experienced by hospitalized patients with varied DSM-IV diagnoses regularly treated with antipsychotic medication. METHOD: We examined the medical records of 204 hospitalized patients. All medical records were examined retrospectively from consecutive admissions beginning in January 1996. We identified demographics, length of hospitalization, diagnosis, and antipsychotic and adjunct medication. EPS were classified into dystonia, parkinsonism, akathisia, and tardive dyskinesia (TD). For each type of EPS, 2 independent raters rated the quality of assessment based on dimensions of severity, location, and laterality. RESULTS: The extent of interrater agreement was found to be 91.1%. Parkinsonism and akathisia were more frequently assessed, compared with TD and dystonia. However, the medical records examined showed generally poor assessment and documentation of EPS. The percentage of medical records with "no description" for each EPS classification was as follows: dystonia (89%), parkinsonism (71%), akathisia (67%), and TD (94%). CONCLUSIONS: The major finding of this study was a high rate of failure to document the assessment and course of EPS. This finding suggests that clinicians do not recognize the importance of documenting these significant adverse events. This shortcoming can be corrected with increased awareness of EPS and increased training in their physical examination.

Switching from conventional to novel antipsychotic drugs: results of a prospective naturalistic study.

OBJECTIVE: We examined the long-term consequences of switching patients from conventional to novel antipsychotic drugs, from a patient's perspective. METHODS: In a prospective, single-blinded, naturalistic study, a cohort of subjects (n=150) with schizophrenia or schizo-affective disorder (DSM-IV) were switched from conventional neuroleptic drugs to either risperidone (n=50), olanzepine (n=50) or quetiapine (n=50), and monitored for a period of 2 to 6 years. The ensuing natural history of transitions in treatments was charted, and the outcomes including symptoms, side effects, subjective tolerability of drugs and their impact on quality of life were documented with standardized rating scales. RESULTS: Majority (85%) of the subjects benefited from a switch to the novel antipsychotic drugs, though some preferred to return to their original neuroleptic (8%), and others eventually required clozapine (7%) therapy. Novel antipsychotic drugs were significantly tolerated better, and had a positive impact on treatment-adherence, psychosocial functioning and quality of life. Among the novel drugs, risperidone was significantly better in improving negative symptoms, while olanzepine was particularly well tolerated and effective against comorbid anxiety and depressive symptoms. Patients treated with quetiapine reported fewer side effects, and showed a significantly greater improvement in neurocognitive deficits. CONCLUSION: Novel antipsychotics emerged as the drug of choice in view of their overall effectiveness, though conventional neuroleptics and clozapine will continue to have a limited but distinct role in the management of schizophrenia. The challenge for clinicians lies in matching a patient's clinical and biochemical profile with that of a drug's pharmacological actions, in order to achieve optimum outcomes.

A comparison of long-term outcome in first-episode schizophrenia following treatment with risperidone or a typical antipsychotic.

BACKGROUND: Most reports assessing the efficacy and tolerability of risperidone have involved patients previously treated with typical antipsychotics. Such patients are more likely to have a greater resistance or intolerance to treatment, thus restricting our interpretation of the impact a new treatment might have on the course of schizophrenia and possibly biasing the results. The present study examines the relative effectiveness of risperidone and typical antipsychotics in patients being treated for their first episode of schizophrenia. METHOD: From a cohort of 126 patients, 2 groups of 19 first-episode DSM-III-R/DSM-IV schizophrenia patients matched for age, gender, length of illness, and length of treatment and treated with either a typical antipsychotic or risperidone for a minimum of 1 year were compared on a number of outcome dimensions during their course of treatment and at follow-up. Treatment allocation was not random, and patients were judged to be compliant with medication. Patients treated with typical antipsychotics were followed up for a statistically nonsignificantly longer time (mean = 2.7 vs. 1.9 years). RESULTS: Six patients (31.6%) from the typical antipsychotic group were admitted to the hospital within the first year following the index admission compared with 1 patient (5.3%) in the risperidone group (admitted at month 14). Patients in the risperidone group showed a statistically significantly lower length of first hospitalization (p < .01), utilization of inpatient beds during the course of treatment (p < .001), and use of anticholinergic medication (p < .05). There were no statistically significant differences in symptom levels, either during the course of treatment or at follow-up; in the use of antidepressant, antianxiety, or mood-stabilizing drugs; or in changes in living circumstances or employment. CONCLUSION: These findings confirm at least equal long-term efficacy of typical antipsychotics and risperidone, but a possible advantage for risperidone in decreased service utilization and decreased use of anticholinergic drugs.

Switching from therapy with typical antipsychotic agents to risperidone: long-term impact on patient outcome.

This paper reports the results of a retrospective, open-label study in 31 schizophrenic patients who had been switched from therapy with a typical antipsychotic agent to risperidone, a novel antipsychotic agent, in the course of their treatment in an outpatient/community program. The study was based on both a review of all 31 patients' charts and a structured interview of 26 of the patients. The change to risperidone had been made because of lack of efficacy or intolerance to typical antipsychotic agents after a mean of 3.5 years of therapy. Patients had been maintained on risperidone for a mean of 1.7 years at the time of the review. The impact of switching to risperidone was assessed by comparing clinical variables for the patients with their own historic control data. The current levels of symptoms, side effects, and social functioning were also assessed by means of the Interview for Retrospective Assessment of Onset of Schizophrenia and rating scales. Seventy-one percent and 81% of the patients exhibited a positive response, as measured by a 30% reduction in psychotic and disorganization syndromes, respectively. After the switch, significant declines were noted in service utilization; the level of psychotic, disorganization, and negative symptom dimensions; and the use of anticholinergic drugs (P < 0.01 for all). Assessments conducted at the time of the review revealed a low level of psychotic (mean, 3.5) and disorganization (mean, 3.0) symptoms, a moderate level of negative symptoms (mean, 19.5), and a low level of extrapyramidal symptoms (total mean parkinsonism score, 6.0). No significant changes were seen in the level of employment or in living conditions. Results of this study suggest that a switch to risperidone therapy because of the inefficacy of typical antipsychotic agents or patients' inability to tolerate them may lead to sustained and significant improvement in a substantial proportion of patients with schizophrenia.