Potential adverse effects of discontinuing psychotropic drugs. Part 3: Antipsychotic, dopaminergic, and mood-stabilizing drugs.

Abrupt discontinuation of antipsychotic drugs in patients with schizophrenia is associated with earlier, and often more severe, illness episodes than are seen with gradual discontinuation. Antipsychotic drugs can cause various abnormal motor syndromes, but abruptly stopping them has been associated with the seemingly paradoxical development of similar motor syndromes, such as withdrawal dyskinesias, parkinsonian symptoms, dystonias, and neuroleptic malignant syndrome. Dopamine-releasing and dopamine-agonist drugs are used to treat some of the motor syndromes caused by antipsychotic drugs, but their abrupt discontinuation can also be associated with abnormal syndromes. When antipsychotic drugs, lithium, or certain anticonvulsant drugs are used for treatment of bipolar disorder, rapid versus gradual discontinuation is more likely to lead to greater mood instability and manic relapse. If necessary, these medications should be gradually tapered to minimize all types of adverse discontinuation effects. Patients should be educated about the possible adverse effects of abrupt medication discontinuation.

Development of a screening tool to assess risk of tardive dyskinesia.

This article gives an overview of antipsychotic medication and of tardive dyskinesia (TD). It examines the research available on TD as it relates to people with a learning disability (PWLD). The evidence identifies that specific groups of people are at an increased risk of developing TD. It also shows that 45-50% of PWLD who are treated with antipsychotic medication will be affected by TD. The evidence is used in the formulation of an assessment tool designed for use by the community learning disability nurse to identify an individual's risk of developing TD before commencing medication. Litigation in the USA has led to a $6.7 m award for sound, clinically effective practice and evidence-based interventions requires that practitioners are accountable for their practice, but are also seen to transform existing services in a way which improves the delivery of quality interventions and care.

What can we do about acute extrapyramidal symptoms?

Antipsychotic drugs are the most effective treatment for psychotic disorders such as schizophrenia. However, they are known to cause a range of side-effects including acute extrapyramidal symptoms (EPS) that are both distressing and disabling. Mental health nurses play a critical role in both the detection and the management of these symptoms. A review of the literature was conducted to identify strategies for managing acute EPS. Despite a widely held belief that EPS are associated with noncompliance with medication, the data to support this hypothesis are weak. Although akathisia may negatively affect the treatment outcome, there was little evidence to suggest that parkinsonism or dystonia do. Whilst the use of anticholinergic medication may be helpful in treating acute parkinsonism and dystonia they were associated with their own side-effects and the benefit of long-term prophylactic treatment is doubtful. The literature suggests that logical prescribing and rapid detection and management of acute EPS will result in a substantial reduction in the incidence of these disabling side-effects.

A screening system for tardive dyskinesia: development and implementation.

1. Most diagnosed cases of tardive dyskinesia (TD) are mildly inconvenient to the patient, but some can be severe or life-threatening. The primary goal of intervention should be early identification of abnormal movements related to TD and the prescribing of an appropriate medication regimen. 2. Unless specific training occurs and a specific monitoring system is in place, TD movements may be missed. However, not all movements are necessarily related to TD. 3. Although screening and monitoring are valuable, nothing is more important than prevention. New medications must be developed that do not carry the risk of TD, and other approaches to treat TD must be developed.

Drug-induced and tardive movement disorders.

Drug-induced and tardive movement disorders represent a large number of extrapyramidal disorders seen in neurologic practice. Iatrogenically induced, most commonly by neuroleptics, these disorders can be characterized by any abnormal body movement including tremor, chorea, athetosis, dyskinesias, dystonia, myoclonus, tics, ballismus or akathisia. Parkinsonism, dyskinesias and dystonia tend to be the most common. Management of patients with drug-induced or tardive syndromes is complex. Prognosis is frequently poor as patients usually need the offending agent to manage their underlying psychiatric or medical problem. Neuroleptics and other drugs known commonly to cause movement disorders should be used cautiously and significant consideration of all risks and benefits measured before initiating therapy.

Tardive dyskinesia: a key issue facing the psychiatric/mental health nurse.

The use of psychotropic drugs over the past four decades has helped calm violent behavior in psychiatric patients. However, a significant number of patients using these drugs have developed tardive dyskinesia, a potentially irreversible neurological syndrome that causes a variety of involuntary movements of the head, face, and body. The nurse can play a large role in structuring a written informed consent document and a well-coordinated TD monitoring system to protect patients and prevent lawsuits.