Should chronic treatment-refractory akathisia be an indication for the use of clozapine in schizophrenic patients?
BACKGROUND
Clozapine, an atypical neuroleptic, is an effective medication in a subgroup of schizophrenic patients who have either failed to respond to the typical neuroleptics or experienced intolerable side effects such as neuroleptic malignant syndrome and disabling tardive dyskinesia. Its efficacy for persistent and disabling akathisia is less clear. Akathisia, especially the chronic and disabling form, can be a treatment dilemma for the clinician and the patient.


METHODS
We describe three representative case illustrations of schizophrenic patients who had severe, persistent treatment-resistant akathisia. Two of them had refractory psychoses and the third had multiple disabling side effects during treatment with typical neuroleptics. Two had tardive dyskinesia. These patients were treated with clozapine while other neuroleptics were discontinued.


RESULTS
During a 2-year follow-up, these patients made impressive social and vocational strides coinciding with a fairly rapid remission of akathisia (under 3 months) and a lesser though notable improvement in the psychoses. Tardive dyskinesia also remitted, though over a period of 6 to 12 months.


CONCLUSIONS
Our experience leads us to suggest a trial of clozapine in a subgroup of schizophrenic patients, who in addition to refractory psychoses have persistent disabling akathisia. However, given the risk of agranulocytosis with clozapine, we suggest that the usual treatment strategies for akathisia be tried before clozapine is initiated in the approved manner. Future controlled trials of clozapine that specifically investigate persistent akathisia may answer this question more conclusively.
Levin
H
H
Department of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh-School of Medicine, PA 15213-2593.
Chengappa
K N
KN
Kambhampati
R K
RK
Mahdavi
N
N
Ganguli
R
R
D000328:Adult; D000380:Agranulocytosis / Q000139:chemically induced; D017109:Akathisia, Drug-Induced; D014150:Antipsychotic Agents / Q000009:adverse effects; D002908:Chronic Disease; D003024:Clozapine / Q000009:adverse effects / Q000627:therapeutic use*; D004409:Dyskinesia, Drug-Induced / Q000188:drug therapy / Q000209:etiology; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011595:Psychomotor Agitation / Q000150:complications / Q000188:drug therapy*; D012559:Schizophrenia / Q000150:complications / Q000188:drug therapy*; D012565:Schizophrenic Psychology; D012917:Social Adjustment
D014150:Antipsychotic Agents; D003024:Clozapine