Tardive Dyskinesia Quiz: Medical Comorbidities

Question 1: (answer and Question 2 on the next page)

All of the following medical comorbidities are risk factors for TD except:

A. Alcohol and substance use disorder

B. Diabetes mellitus

C. Hyperlipidemia

D. Human immunodeficiency virus

The correct answer is C. Hyperlipidemia

Discussion

Alcohol use, diabetes, and HIV are medical comorbidities that are independent risk factors for Tardive dyskinesia (TD). Other well-replicated risk factors for TD include older age, African-American race, early extrapyramidal symptoms, and a higher dose and longer duration of exposure to antipsychotics.^1,2

Question 2 (answer and Question 3 on the next page)

Potential adverse consequences of TD include which of the following:

A. Increased stigma

B. Poorer quality of life

C. Increased medical comorbidity

D. Increased mortality

E. All of the above

The correct answer is E. All of the above

Discussion

TD is a potential socially stigmatizing condition.³ There is also evidence that TD is associated with a poorer quality of life in patients with schizophrenia.⁴ One study found that patients with schizophrenia and comorbid TD were more likely to show smoking-related pathology, have recurrent respiratory tract infections, and have increased cardiovascular disorders.⁵ A meta-analysis of 7 studies, with a median follow-up period of 4 years, found a significantly, 1.4-fold increased risk of mortality in patients with schizophrenia or affective disorders and TD.⁶

Question 3 (Answer on the next page)

A patient whose schizophrenia is treated with haloperidol for 15 years is diagnosed with antipsychotic-induced TD by the treating psychiatrist. If clinically indicated, switching to which of following antipsychotics may be most beneficial for this patient?

A. Perphenazine

B. Risperidone

C. Olanzapine

D. Clozapine

The correct answer is D. Clozapine

Discussion

Whenever possible (based on a discussion of risks and benefits with the patient), treatment of TD includes discontinuation of the presumed causative antipsychotic. If clinically indicated, evidence from clinical trials and case series/reports suggests that treatment with clozapine is associated with improvements in TD.^7,8 Furthermore, the risk of new-onset TD in patients treated with clozapine is low (though not zero).

This quiz was originally published on December 17, 2017 and has since been updated. -ED.

References:

1. Jankelowitz SK. Treatment of neurolept-induced tardive dyskinesia. Neuropsychiatr Dis Treat. 2013;9:1371-1380.

2. Tenback DE, van Harten PN, van Os J. Non-therapeutic risk factors for onset of tardive dyskinesia in schizophrenia: a meta-analysis. Move Disord. 2009;24:2309-2315.

3. Lerner PP, Miodownik C, Lerner V. Tardive dyskinesia (syndrome): current concept and modern approaches to its management. Psychiatry Clin Neurosci. 2015;69:321-334.

4. Browne S, Roe M, Lane A, et al. Quality of life in schizophrenia: Relationship to sociodemographic factors, symptomatology and tardive dyskinesia. Acta Psychiatr. Scand. 1996;94:118–124.

5. Ballesteros J, Gonzalez-Pinto A, Bulbena A. Tardive dyskinesia associated with higher mortality in psychiatric patients: results of a meta-analysis of 7 independent studies. J Clin Psychopharm. 2000;20:188-194.

6. Youssef HA, Waddington JL. Morbidity and mortality in tardive dyskinesia: Associations in chronic schizophrenia. Acta Psychiatr. Scand. 1987;75:74–77.

7. Hazari N, Kate N, Grover S. Clozapine and tardive movement disorders: a review. Asian J Psychiatr. 2013;6:439-451.

8. Spivak B, Mester R, Abesgaus J, et al. Clozapine treatment for neuroleptic-induced tardive dyskinesia, parkinsonism, and chronic akathisia in schizophrenic patients. J Clin Psychiatry. 1997;58:318-322.