Objective: To characterize patients with neuroleptic drug-induced movement disorders (DIMD) referred to a single academic center Movement Disorders clinic, their causative medications and the indications for their use.

Background: First-generation antipsychotic medications that block dopamine receptors (DRBA) are associated with a significant risk of DIMD. The introduction of second generation, or so-called atypical DRBAs decreased the incidence of tardive dyskinesia by half.¹ Thus, a plethora of new second generation DRBAs have been used for increasingly broader indications. Nevertheless, recent studies suggest that the incidence of DIMD has not decreased since the introduction of newer DRBAs.² 

Methods: We conducted a retrospective medical records review of patients with a diagnosis of DIMD at the Movement Disorders Clinic of the Yale School of Medicine from July 2014 to July 2016. Clinical and demographic information was extracted, including age, gender, co-morbidities, phenomenology of the movement disorder, causative agent, and indication for its use. We classified each indication as on or off label based on FDA guidelines. Descriptive statistics were generated for all variables. 

Results: A total of 72 patients were included in the study, 44 were females and 28 males. The mean age was 55.22 (±14.61). 43 patients had been exposed to atypical DRBAs, 12 to typical DRBAs, 2 were exposed to metoclopramide and 1 to bupropion. 14 patients had a history of both typical and atypical antipsychotic use. Aripiprazole and risperidone were the 2 atypical DRBAs most frequently used. Drug-induced parkinsonism was the most frequent DIMD diagnosis (n=33) followed by tardive dyskinesia (n=17) and tardive dystonia (n=8). The most frequent indications for use were bipolar disorder (n=23), schizophrenia (n=18) and depression (n=18). 19 of the 72 patients had an off-label indication (26%). Depression was the most common indication for off label use, followed by bipolar disorder. Combination of typical and atypical antipsychotics were most frequently used off label (n=5). The atypical antipsychotic most frequently used off-label was risperidone. 

Conclusions: Atypical DRBAs were most frequently associated with DIMD in this single center study. 26% of patients had an off-label indication of use. Patients and caregivers should be well-informed about the possibility of irreversible neurological side effects from these medications, especially when used in an off-label fashion.

References: 1- Dolder C.R., Jeste D.V.: Incidence of tardive dyskinesia with typical versus atypical antipsychotics in very high risk patients. Bill Psychiatry 2003; 53 (12):1142-1145 

2- Woods S, Morgenstern H, et al. Incidence of tardive dyskinesia with atypical and conventional antipsychotic medications: Prospective cohort study. J Clin Psychiatry 2010 April; 71 (4): 463-474

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