Before we assess the present neuroleptic trial for adequacy, we would like to know if this patient has had a previous adequate trial of a standard typical neuroleptic in which there was unsatisfactory response while at the same time the patient developed definite neuroleptic-induced parkinsonian side effects.* By "adequate trial" we mean 8 weeks of no response, or a trial of any length with partial improvement that plateaued at an unsatisfactory level for at least 8 weeks. If the patient has had an adequate trial like this, click here. There is no need to assess the present neuroleptic trial for adequacy because the previous trial may be considered to be representative of how the patient would respond to any standard typical neuroleptic. Further comments and explanation will follow at this link. But, if the patient has not had such a trial in the past, or you are uncertain, continue by reading the comment below and answering the questions that follow.
Comment. The next step in assessing this patient will be to investigate for evidence of bioavailability (in the brain) of this neuroleptic. Parkinsonism is considered to be the prime evidence of central bioavailability of this type of antipsychotic. For a more detailed discussion of this, click on the pop-up menuin the frame below where it says "Other choice," and select "Assessment of Parkinsonism."
The key signs of parkinsonism are rigidity of the cogwheel type, akinesia, and tremor (regular, rhythmic, 4-6 beats per second, noted at rest (and usually disappears with voluntary movement of the affected joint). Akathisia (restlessness, shaking, or need to move limbs to relieve an uncomfortable sensation in the muscles) is not considered a sign of parkinsonism.
Clinicians may use any examination process for detecting parkinsonism that they are accustomed to use. Perhaps the most sensitive examination procedure is the "Neuroleptic Threshold Examination," which is described below in the link to "Assessment of Parkinsonism." A common research assessment is the Simpson-Angus Scale for Extrapyramidal Side effects, which includes assessments for parkinsonism as well as other movement disorders in patients on neuroleptics.
*Examples of neuroleptic-induced parkinsonism include a parkinsonian tremor (regular, rhythmic, 4-8 beats per second, generally symmetrical) most noted at rest; cogwheel rigidity, and behavioral akinesia (masked facies, shuffling gait, absent armswing). Akathisia is NOT considered an example of parkinsonism for the purposes of this question.
¹Subsyndromal Depressive Syndrome, or Depression NOS in DSM-4, is a major public health problem that produces significant functional impairment. See Judd LL. Socioeconomic burden of subsyndromal depressive syndrome and major depression in a sample of the general population. Am J Psychiatry 1996;153:1411-1417.
²Mason BJ, Kocsis JH, Ritvo EC, Cutler RB. A double-blind, placebo-controlled trial of desipramine for primary alcohol dependency stratified in the presence or absence of major depression. JAMA March 13, 1996;275(10):761-767.
³Gelenberg A. Biological Therapies in Psychiatry Newsletter 1996;19(7):25-26.