Question:

Dear Doctor,

My 18 year old son has developed paranoid thinking and seems to be hearing voices that the rest of us cannot. He is staying up all night and sleeping during the day. He leaves the house in the middle of the night and we don’t know where he is going or what he is doing. He had just started his first year of college but came home and didn’t bring all of his belongings. We took him to a psychiatrist who said that he is psychotic and may have Schizophrenia or depression. Apparently my son is not sick enough to hospitalize. He is currently refusing to take any type of medication but he will see the Psychiatrist.

I've been doing some reading on anti-psychotic drugs and have run across something that concerns me. I've read that over 70% of patients that take anti-pychotic drugs develop Tardive Dyskinisia. It is a grim disorder. Can you give me any information you know on this topic, please?

Concerned

Dear Concerned,

You have reason to be worried. The questions that you are asking have very complex answers. I will try to give you the simplified version and include internet links to sites that will give you further information and support.

You should not delay in getting your son treated with medications. There is a general feeling in the psychiatric community that the sooner psychotic symptoms are successfully treated, the better.

It is very common to have an individual like your son refuse medication. Sometimes this is because of the side effects; often it is because of fear of friends judging one having to take medication; sometimes just plain paranoia. Since your son has not tried the medications, I would assume the latter explanations best describe his reasons.

He needs a skilled and caring mental health professional, probably not a psychiatrist since their time is limited and expensive, who can establish a trusting relationship with your son and guide him through treatment with antipsychotic medications. It will be most helpful if medications are started slowly with frequent feedback from your son to make sure that he continues to accept the treatment and that any bad side effects are caught early. These medications can have significant side effects. It is important that the mental health professional working with your son knows the common side effects and is able to help your son relay any concerns to his psychiatrist.

Now, I will address your questions about the neurological side effects of the antipsychotic medications. There are two major types of neurological side effects. Tardive Dyskinesia, which you mention, is less common with the newer antipsychotic medications. It typically develops more with each year of medication treatment and is most common in elderly patients. There is no treatment other than changing or discontinuing the medications. The good news is that the incidence is dropping because of newer medications with fewer side effects and reduced need for patients to be on medications for long periods of time.

The second and more common type of neurological side effect of antipsychotic medications are those which are have more immediate symptoms. These include “restless legs”… a type of pacing and inability to sit down and concentrate, or twitches or muscle rigidity. Another is an acute reaction where the muscles contract and the eyes roll back. Most all of these are less frequent with the newer atypical antipsychotics. They also can be treated with medications such as Cogentin or Benadryl. Decreasing, stopping or changing the medications can also be very effective.

For all of the above reasons, it would be best that your son be immediately placed on one of the newer “atypical” antipsychotics to begin with and then monitored for any neurological symptoms. The dosage should start low and slowly increased in order to have best treatment response with least side effects.

Resources for further information include the National Alliance for Mental illness:

http://www.nami.org/

The following articles on web sites are more specific:

http://www.nami.org/Content/ContentGroups/Helpline1/Tardive_Dyskinesia.htm

http://www.hubin.org/publicfamilyinfo/treatment/side_effects/side_effects_6_en.html

I wish you and your son well. I hope that you can find a knowledgeable mental health professional to work with your son, and an up to date psychiatrist to prescribe his medications.

Kay S. Browne MD
Behavioral Pediatrician