College of Psychiatric and Neurologic Pharmacists

Movement disorders have many different presentations and are defined as a group of syndromes that affect the ability for one to control movement in a given muscle or muscle group. Many of the medications we use to treat psychiatric illness (antipsychotics, lithium, and valproic acid) have the potential to cause movement disorders, often referred to as extrapyramidal side effects, though predictability is lacking. Antipsychotic-induced dopamine blockade can lead to acute dystonia, akathisia, and Parkinsonism, all of which are generally reversible if treatment is discontinued. A neuroleptic-induced movement disorder that may be irreversible is tardive dyskinesia. Both lithium and valproic acid may cause tremor, the presentation of which will be explored in this issue of the Mental Health Clinician. Less often, our antidepressants may induce movement disorders similar to those caused by antipsychotics. In 2009, the U.S. Food and Drug Association placed a black box warning on the medication metoclopramide, a gastrointestinal motility agent that has some dopamine blockade effects, warning of its risk of causing tardive dyskinesia. This prompted a slew of lawsuits against manufacturers of this medication and the doctors who prescribed it without informing or monitoring their patients for this known side effect. Read the full editorial.

“Why Not Clozapine?” asked Kelly and colleagues over 4 years ago in a Clinical Schizophrenia article.¹ Apparently, few heard the question and still fewer answered. In 2011, over 20 years since clozapine was marketed in the U.S., its use is at an all-time low. In 1999, 11% of second generation antipsychotic prescriptions were for clozapine in the U.S. Today, only 2-3% of antipsychotic prescriptions are for clozapine.¹ This is despite overwhelming evidence of its effectiveness for treatment-resistant schizophrenia, suicide prevention in schizophrenia, reductions in hospitalizations, and other pharmacoeconomic data supporting the use of clozapine. Dr. Herbert Meltzer stated, “leading economists have cited the underuse of clozapine for treatment resistance and suicide as one of the two greatest failures of mental health providers to practice evidence-based medicine.”² Most experts feel the use of clozapine in the U.S. is currently far below the estimated need. Read the full editorial.

September is National Alcohol and Drug Addiction Recovery Month. Addiction is a compulsive, drug-seeking behavior, characterized by a loss of control that leads a person to continually acquire and use the drug/substance, despite serious medical and/or social consequences. In 2009, the National Survey on Drug Use and Health reported that an estimated 20.8 million adults were identified as having a substance use disorder, defined as dependence on or abuse of an illicit drug or alcohol. Pharmacists are well-positioned to address substance use disorders with regards to identification and education, but the ways in which pharmacists are involved in addressing substance use disorders remain unclear. This issue of the Mental Health Clinician explores the implications of co-occurring disorders on medication adherence and pain management.  The role of a pharmacist in substance use disorder research is also described and the need for addiction education for future pharmacists is discussed. Read the full editorial.