Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by University of British Columbia on 12/11/14 For personal use only.
AM. J. DRUG ALCOHOL ABUSE, 16(1 & 2). pp. 57-66 (1990)
Tardive Dyskinesia in Psychiatric Patients with Substance Use Dis0rders Arturo A. Olivera,' MD Veterans Addiction Recovery Center Cleveland Veterans Administration Medical Center Bmksville Division Brecksville, Ohio 44 141; Department of Psychiatry Case-Western Reserve University Cleveland, Ohio 44 106
Mary W. Kiefer, RN, MS Norlee K. Manley, RN, BSN, CNA Cleveland-Veterans Administration Medical Center Brecksville Division Brecksville, Ohio 44 141
The authors report on the incidence of tardive dyskinesia (TD) in a sample of 284 psychiatric patients who chronically abused street drugs; 82.4% had rerxived auvolcptic treatment for the lengthof their illness (10.5 f 5.8 years). The incidcnccof TD was 15.9%. The incidence of TD was signi6cantly higher in groups of patients in which alcohol alone (25.4%) or in combinstionwith calmabb (26.7%) was the h g of abusc thn intfiose gmups in which alcohol was either absent or used in c o m b i i o n with sedatives, Opioids. or stimulants. Tardive dyskincsii was absent in p a t i e not treated with eeurolepics and in a control group of drug abusers fne of mental diaordcrs. The anatomical distribution was similar to rhat reported in 0tbapsychiatrics;llllPles.McanscVaity w a s m i l d a r d i n q d a h arddistnsswaeminimal. Polydrug abuse waa dominant in both patients and controls, and alcohol abuse was more
T o whom requests for reprints should be addressed at Western Reserve Psychiatric Hospital, P.O. Box 305, Northfield. Ohio 44141.
57
58
OLIVERA, KIEFER. AND MANLEY
frequent among TD patients. It is concluded that chronic use of alcohol by mental patients undergoing p h m m m h q y with neuroleptics enhsncts thc vulncrabity of these patients to TD.
Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by University of British Columbia on 12/11/14 For personal use only.
INTRODUCTION Tardive dyskinesia (TD), a neurological disorder characterized by choreoathetotic involuntary movements (IMs) that affect various areas of the musculoskeletal system of psychiatric patients [ 11, is the major long-term complication of neuroleptic treatment [2]. Reports on the incidence of this disorder vary widely, ranging from 10 to 70% [3]. It is recognized that organic brain disorders may predispose psychiatric patients toward the development of TD [4]; however, the literature contains very little on the influence of chronic psychoactive substance abuse on the incidence of this disorder. It is possible that the brain damage produced by chronic exposure to the toxic effects of illicit drugs could increase the vulnerability to TD when drug users are treated with neuroleptics. The development of IMs similar to TD has been reported in conjunction with the use of L-DOPA, antihistamines, anticholinergics, anticonvulsants, and central nervous system (CNS)stimulants [5, 61. The purpose of the present study was to determine the incidence and the anatomical characteristicsof TD in a sample of psychiatric patients, who abuse illicit drugs (dual psychiatric disorder), while undergoing treatment with neuroleptic medication. The study also examined the relationship between the development of TD and the nature of the psychoactive substance abused.
METHODS Two-hundred-eighty-fourfirst admissions to an inpatient unit specializing in the treatment of major mental disorders complicated by substance abuse were screened for IMs.Except for two subjects, all patients were male. All subjects were chronic illicit drug users and had at least one major psychiatric diagnosis; 234 (82.4%) were treated with neuroleptics, while the remaining 50 (17.6%) had never received neuroleptics. Sixty-four percent of these patients carried the diagnosis of schizophrenia, 14% other psychosis, 10% affective disorders, and 12% other diagnoses. Patients treated with neuroleptics had received a mean f SD chlorpromazine equivalent of 935 f 710 mg/day. The control group (N = 100) included individuals randomly extracted among substance users admitted to an inpatient drug treatment program; this group was observed to determine
Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by University of British Columbia on 12/11/14 For personal use only.
TARDIVE DYSKINESIA IN PSYCHIATRIC PATIENTS
59
the influence of drug usage on the incidence of TD. The exclusion criterion for this group was the current andor past history of either mental disorder or neurolep tic intake. Tardive dyskinesia was independently assessed and rated by two experienced raters (A.A.O. and M.W.K.) in those individualswith positive signs of IMs. The control group was also screened for IMs by two screeners (A.A.O. and N.K.M.). The Abnormal Involuntary Movement Scale ( A I M S ) was used for the assessment, diagnosis, and rating of TD severity. This instrument is widely accepted for its reliability and clinical usefulness [7].The AIMS utilizes a 5-point rating scale (0 = absent to 4 = severe) to rate individual area or global severity, incapacitation, distress, and awareness. All seven areas of anatomical distribution of TD, i.e., facial, perioral, lingual,jaw, upper and lower limbs, and trunk,were assessed. Age-related distribution of TD was calculated using 10-year intervals. The patients’ history of substance abuse was elicited by a self-report questionnaire and a structured interview which included age of onset, type and quantity of drugs used, frequency, and complications. When available, previous patient records were used to confirm the drug history. All patients in the study met the requirements for a DSM-III diagnosis of chronic psychoactive substance dependence, complicated in all or some of the health, personal, family, social, financial, occupational, and legal areas. The pattern of psychoactive drug use was established in both the patient and the control samples. The incidenceof TD was calculated according to drug groups. Analysis of variance was utilized to determine the significance of integroup differences. Significance was set at p c .05
RESULTS Table 1 includes the demographiccharacteristics and the mental and substance abuse history data for the patients affected by TD compared to those without the dyslcynetic disorder. Although patients having TD were significantly older, the length of their mental illness was not statistically different from patients free of TD. Patients with TD also had a significantly longer history of concomitant substance use disorder. The groups did not differ significantly in terms of age of onset for either mental illness or substance abuse problems. Table 2 presents the characteristics of substance abuse in both TD and control groups. TD patients abused mostly alcohol, with a lesser frequency of cannabis usage; concurrent abuse of other drugs was significantlylower than in the control group. While polydrug abuse was the dominant pattern in the control group, TD patients abused
OLIVERA, KIEFER, AND MANLEY
60
Table 1. Demographic Characteristics of the sample of Dual Psychiatric Disorder Patients Studied: A. Patients without TD (N = 224); B. Patients Identified as Affected by TD (N = 37); C. Control Group. Substance Abusers “Free” of Mental Disorders (N = la0)
Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by University of British Columbia on 12/11/14 For personal use only.
A
B
Mean
S.D.
Mean
Age
32.4
7.4
37.2
Mental illness: Age of onset Length (Years)
20.5 11.9
5.9 7.0
17.3 15.1
4.5 7.7
Substance abuse: Age of onset Length (Y-1 Racial distribution (%): Whites Blacks
61.6 38.4
C Mean
S.D.
8.9
36.7
6.9.
24.3 13.4
10.5 6.2
-
16.4 21.2
3.1 9.5
18.7 15.2
S.D.
70.3 29.7
-
-
11.5 6.7b 38.0 62.0
a
p value for intergroup difference was .002 for B-A and A-C. ’p value for intergroup difference was .002 for B-A and B-C.
one or two drugs predominantly (Table 2, Section II), i.e., alcohol alone or in combination with cannabis (Table 2, Section ID). The incidence of TD, influence of treatment, and racial distribution of the dyskinetic disorder are presented in Table 3-A. This disorder was found only in those patients treated with neuroleptic drugs; neither untreated patients nor control subjects exhibited signs of the disorder. Among the TD patients, 70.3% were Whites and 29.7% Blacks; the incidenceof the disorder was somewhat higher in Whites. Table 3-B summarizes the differences in the incidence of TD in those patients using only alcohol andor cannabis versus those patients who used other drugs. The differences between single substance users and polysubstance users are summarized in Table 3-C. A significantlyhigher percentage of alcohol and/or cannabis users and of single substance users were found to be affected by TD. Table 4 presents the age-related distribution of the TD patients in this study sample as compared to findings by other authors. According to this study, the greater incidence occurred between the ages of 40 and 59 (Table 4-A). As presented in Table 5 , the anatomical areas most frequently affected were those of the head and upper limbs; the lower limbs were affected less frequently. The trunk was also affected in approximately50% of cases. The severity of the disorder
61
TARDIVE DYSKINESIA IN PSYCHIATRIC PATIENTS
Table 2. Characteristics of Psychoactive Substance Use in Patients Simultaneously Affected by Mental and Substance Use Disorders: A. Patients Free of Tardive Dyskinesia (N= 247); B. Tardive Dyskinesia Patients (N = 37); C. Control Group: Substance Users Free of Mental Disorders (N =
Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by University of British Columbia on 12/11/14 For personal use only.
Occurrence (96) A
B
C
87.4* 70.4
94.62 59.5
64.0
32.0
8.1
87.0
27.1 45.8
8.0 18.9
70.0 83.0
4. Sedatives (Benzodiazepines, barbiturates)
45.3
11.0
64.0
5. Hallucinogens (PCP, LSD,MDA)
26.3
10.8
38.0
6. Others Talwin-Pyribenzamine Organic solvents
11.3* 2.0
2.7* 0.0
31.0 0.0
17.4 36.4 38.9 7.3
35.1 46.0 18.9 0.0
2.0 20.0 45.0 33.0
15.4 14.2 29.6
35.0 35.0 70.0
0.0 0.0 0.0
I. Psychoactive drugs 1. Sedative-Stimulants Alcohol Cannabis 2. Narcotics Opioids 3. Stimulants Cocaine Amphetamines
+ Ritalin + Preludin
83.0
II. Number of drugs used 1 2-3 4-6 7
Ill. Alcohol and cannabis use, only Alcohol, only Alcohol-cannabis, only Alcohol + Alcohol-cannabis
'p value for intergroup differences was
AM. J. DRUG ALCOHOL ABUSE, 16(1 & 2). pp. 57-66 (1990)
Tardive Dyskinesia in Psychiatric Patients with Substance Use Dis0rders Arturo A. Olivera,' MD Veterans Addiction Recovery Center Cleveland Veterans Administration Medical Center Bmksville Division Brecksville, Ohio 44 141; Department of Psychiatry Case-Western Reserve University Cleveland, Ohio 44 106
Mary W. Kiefer, RN, MS Norlee K. Manley, RN, BSN, CNA Cleveland-Veterans Administration Medical Center Brecksville Division Brecksville, Ohio 44 141
The authors report on the incidence of tardive dyskinesia (TD) in a sample of 284 psychiatric patients who chronically abused street drugs; 82.4% had rerxived auvolcptic treatment for the lengthof their illness (10.5 f 5.8 years). The incidcnccof TD was 15.9%. The incidence of TD was signi6cantly higher in groups of patients in which alcohol alone (25.4%) or in combinstionwith calmabb (26.7%) was the h g of abusc thn intfiose gmups in which alcohol was either absent or used in c o m b i i o n with sedatives, Opioids. or stimulants. Tardive dyskincsii was absent in p a t i e not treated with eeurolepics and in a control group of drug abusers fne of mental diaordcrs. The anatomical distribution was similar to rhat reported in 0tbapsychiatrics;llllPles.McanscVaity w a s m i l d a r d i n q d a h arddistnsswaeminimal. Polydrug abuse waa dominant in both patients and controls, and alcohol abuse was more
T o whom requests for reprints should be addressed at Western Reserve Psychiatric Hospital, P.O. Box 305, Northfield. Ohio 44141.
57
58
OLIVERA, KIEFER. AND MANLEY
frequent among TD patients. It is concluded that chronic use of alcohol by mental patients undergoing p h m m m h q y with neuroleptics enhsncts thc vulncrabity of these patients to TD.
Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by University of British Columbia on 12/11/14 For personal use only.
INTRODUCTION Tardive dyskinesia (TD), a neurological disorder characterized by choreoathetotic involuntary movements (IMs) that affect various areas of the musculoskeletal system of psychiatric patients [ 11, is the major long-term complication of neuroleptic treatment [2]. Reports on the incidence of this disorder vary widely, ranging from 10 to 70% [3]. It is recognized that organic brain disorders may predispose psychiatric patients toward the development of TD [4]; however, the literature contains very little on the influence of chronic psychoactive substance abuse on the incidence of this disorder. It is possible that the brain damage produced by chronic exposure to the toxic effects of illicit drugs could increase the vulnerability to TD when drug users are treated with neuroleptics. The development of IMs similar to TD has been reported in conjunction with the use of L-DOPA, antihistamines, anticholinergics, anticonvulsants, and central nervous system (CNS)stimulants [5, 61. The purpose of the present study was to determine the incidence and the anatomical characteristicsof TD in a sample of psychiatric patients, who abuse illicit drugs (dual psychiatric disorder), while undergoing treatment with neuroleptic medication. The study also examined the relationship between the development of TD and the nature of the psychoactive substance abused.
METHODS Two-hundred-eighty-fourfirst admissions to an inpatient unit specializing in the treatment of major mental disorders complicated by substance abuse were screened for IMs.Except for two subjects, all patients were male. All subjects were chronic illicit drug users and had at least one major psychiatric diagnosis; 234 (82.4%) were treated with neuroleptics, while the remaining 50 (17.6%) had never received neuroleptics. Sixty-four percent of these patients carried the diagnosis of schizophrenia, 14% other psychosis, 10% affective disorders, and 12% other diagnoses. Patients treated with neuroleptics had received a mean f SD chlorpromazine equivalent of 935 f 710 mg/day. The control group (N = 100) included individuals randomly extracted among substance users admitted to an inpatient drug treatment program; this group was observed to determine
Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by University of British Columbia on 12/11/14 For personal use only.
TARDIVE DYSKINESIA IN PSYCHIATRIC PATIENTS
59
the influence of drug usage on the incidence of TD. The exclusion criterion for this group was the current andor past history of either mental disorder or neurolep tic intake. Tardive dyskinesia was independently assessed and rated by two experienced raters (A.A.O. and M.W.K.) in those individualswith positive signs of IMs. The control group was also screened for IMs by two screeners (A.A.O. and N.K.M.). The Abnormal Involuntary Movement Scale ( A I M S ) was used for the assessment, diagnosis, and rating of TD severity. This instrument is widely accepted for its reliability and clinical usefulness [7].The AIMS utilizes a 5-point rating scale (0 = absent to 4 = severe) to rate individual area or global severity, incapacitation, distress, and awareness. All seven areas of anatomical distribution of TD, i.e., facial, perioral, lingual,jaw, upper and lower limbs, and trunk,were assessed. Age-related distribution of TD was calculated using 10-year intervals. The patients’ history of substance abuse was elicited by a self-report questionnaire and a structured interview which included age of onset, type and quantity of drugs used, frequency, and complications. When available, previous patient records were used to confirm the drug history. All patients in the study met the requirements for a DSM-III diagnosis of chronic psychoactive substance dependence, complicated in all or some of the health, personal, family, social, financial, occupational, and legal areas. The pattern of psychoactive drug use was established in both the patient and the control samples. The incidenceof TD was calculated according to drug groups. Analysis of variance was utilized to determine the significance of integroup differences. Significance was set at p c .05
RESULTS Table 1 includes the demographiccharacteristics and the mental and substance abuse history data for the patients affected by TD compared to those without the dyslcynetic disorder. Although patients having TD were significantly older, the length of their mental illness was not statistically different from patients free of TD. Patients with TD also had a significantly longer history of concomitant substance use disorder. The groups did not differ significantly in terms of age of onset for either mental illness or substance abuse problems. Table 2 presents the characteristics of substance abuse in both TD and control groups. TD patients abused mostly alcohol, with a lesser frequency of cannabis usage; concurrent abuse of other drugs was significantlylower than in the control group. While polydrug abuse was the dominant pattern in the control group, TD patients abused
OLIVERA, KIEFER, AND MANLEY
60
Table 1. Demographic Characteristics of the sample of Dual Psychiatric Disorder Patients Studied: A. Patients without TD (N = 224); B. Patients Identified as Affected by TD (N = 37); C. Control Group. Substance Abusers “Free” of Mental Disorders (N = la0)
Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by University of British Columbia on 12/11/14 For personal use only.
A
B
Mean
S.D.
Mean
Age
32.4
7.4
37.2
Mental illness: Age of onset Length (Years)
20.5 11.9
5.9 7.0
17.3 15.1
4.5 7.7
Substance abuse: Age of onset Length (Y-1 Racial distribution (%): Whites Blacks
61.6 38.4
C Mean
S.D.
8.9
36.7
6.9.
24.3 13.4
10.5 6.2
-
16.4 21.2
3.1 9.5
18.7 15.2
S.D.
70.3 29.7
-
-
11.5 6.7b 38.0 62.0
a
p value for intergroup difference was .002 for B-A and A-C. ’p value for intergroup difference was .002 for B-A and B-C.
one or two drugs predominantly (Table 2, Section II), i.e., alcohol alone or in combination with cannabis (Table 2, Section ID). The incidence of TD, influence of treatment, and racial distribution of the dyskinetic disorder are presented in Table 3-A. This disorder was found only in those patients treated with neuroleptic drugs; neither untreated patients nor control subjects exhibited signs of the disorder. Among the TD patients, 70.3% were Whites and 29.7% Blacks; the incidenceof the disorder was somewhat higher in Whites. Table 3-B summarizes the differences in the incidence of TD in those patients using only alcohol andor cannabis versus those patients who used other drugs. The differences between single substance users and polysubstance users are summarized in Table 3-C. A significantlyhigher percentage of alcohol and/or cannabis users and of single substance users were found to be affected by TD. Table 4 presents the age-related distribution of the TD patients in this study sample as compared to findings by other authors. According to this study, the greater incidence occurred between the ages of 40 and 59 (Table 4-A). As presented in Table 5 , the anatomical areas most frequently affected were those of the head and upper limbs; the lower limbs were affected less frequently. The trunk was also affected in approximately50% of cases. The severity of the disorder
61
TARDIVE DYSKINESIA IN PSYCHIATRIC PATIENTS
Table 2. Characteristics of Psychoactive Substance Use in Patients Simultaneously Affected by Mental and Substance Use Disorders: A. Patients Free of Tardive Dyskinesia (N= 247); B. Tardive Dyskinesia Patients (N = 37); C. Control Group: Substance Users Free of Mental Disorders (N =
Am J Drug Alcohol Abuse Downloaded from informahealthcare.com by University of British Columbia on 12/11/14 For personal use only.
Occurrence (96) A
B
C
87.4* 70.4
94.62 59.5
64.0
32.0
8.1
87.0
27.1 45.8
8.0 18.9
70.0 83.0
4. Sedatives (Benzodiazepines, barbiturates)
45.3
11.0
64.0
5. Hallucinogens (PCP, LSD,MDA)
26.3
10.8
38.0
6. Others Talwin-Pyribenzamine Organic solvents
11.3* 2.0
2.7* 0.0
31.0 0.0
17.4 36.4 38.9 7.3
35.1 46.0 18.9 0.0
2.0 20.0 45.0 33.0
15.4 14.2 29.6
35.0 35.0 70.0
0.0 0.0 0.0
I. Psychoactive drugs 1. Sedative-Stimulants Alcohol Cannabis 2. Narcotics Opioids 3. Stimulants Cocaine Amphetamines
+ Ritalin + Preludin
83.0
II. Number of drugs used 1 2-3 4-6 7
Ill. Alcohol and cannabis use, only Alcohol, only Alcohol-cannabis, only Alcohol + Alcohol-cannabis
'p value for intergroup differences was
