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Preskorn & Flynn 2015. Determining Whether a Definitive Causal Relationship Exists Between Aripiprazole and Tardive Dyskinesia and/or Dystonia in Patients With MDD


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J Psychiatr Pract. 2015 Sep;21(5):359-69. doi: 10.1097/PRA.0000000000000101.

Determining Whether a Definitive Causal Relationship Exists Between Aripiprazole and Tardive Dyskinesia and/or Dystonia in Patients With Major Depressive Disorder: Part 1.


Department of Psychiatry, University of Kansas School of Medicine-Wichita, Wichita, KS.


This series of columns has 2 3 main goals:

(1) to explain the use of class warnings by the US Food and Drug Administration and

(2) to increase clinicians' awareness of movement disorders that may occur in patients being treated with antipsychotic medications and why it is appropriate and good practice to refrain from immediately assuming the diagnosis is tardive dyskinesia/dystonia (TD). $$$

(3) To train you as an expert witness in malpractice law suits


This first column in the series will focus on the second goal, which will then serve as a case example for the first goal. Clinicians should refrain from jumping to a diagnosis of TD because a host of other causes need to be ruled out first before inferring iatrogenic causation. :unsure:


The causal relationship between chronic treatment with dopamine antagonists and TD is based on pharmacoepidemiology (ie, the prevalence of such movement disorders is higher in individuals receiving chronic treatment with such agents than in a control group). There is nothing pathognomonic [indicative of any specific disease] about movement disorders, nor is there any test that can currently prove a drug caused a movement disorder in a specific individual.


Another goal of this series is to describe the types of research that would be needed to establish whether a specific agent has a meaningful risk of causing TD.


In this first column of the series, we present the case of a patient who developed orofacial dyskinesia while being treated with aripiprazole. In this case, the movement disorder was prematurely called TD, which led to a malpractice lawsuit. :angry:


This case highlights a number of key questions clinicians are likely to encounter in day-to-day practice. We then review data concerning the historical background, incidence, prevalence, and risk factors for 2 movement disorders, TD and spontaneous dyskinesia.


Subsequent columns in this series will review: (1) unique aspects of the psychopharmacology of aripiprazole,

(2) the limited and inconsistent data in the literature concerning the causal relationship between aripiprazole and TD :lol:

(3) the use of class warnings by the US Food and Drug Administration, which are automatically applied to a drug if it belongs to a specific therapeutic or pharmacological class unless the manufacturer provides convincing data that it does not warrant such a class label :o

(4) the types of prohibitively expensive studies that would be needed to determine whether a meaningful causal relationship between aripiprazole and TD exists. -_-





$3,400 via ProPublica


2009: Cancer hospital said I had adjustment disorder because I thought they were doing it wrong. Their headshrinker prescribed Effexor, and my life set on a new course. I didn't know what was ahead, like a passenger on Disneyland's Matterhorn, smiling and waving as it climbs...clink, clink, clink.

2010: Post surgical accidental Effexor discontinuation by nurses, masked by intravenous Dilaudid. (The car is balanced at the top of the track.) I get home, pop a Vicodin, and ...

Whooosh...down, down, down, down, down...goes the trajectory of my life, up goes my mood and tendency to think everything is a good idea.
2012: After the bipolar jig was up, now a walking bag of unrelated symptoms, I went crazy on Daytrana (the Ritalin skin patch by Noven), because ADHD was a perfect fit for a bag of unrelated symptoms. I was prescribed Effexor for the nervousness of it, and things got neurological. An EEG showed enough activity to warrant an epilepsy diagnosis rather than non-epileptic ("psychogenic") seizures.

:o 2013-2014: Quit everything and got worse. I probably went through DAWS: dopamine agonist withdrawal syndrome. I drank to not feel, but I felt a lot: dread, fear, regret, grief: an utter sense of total loss of everything worth breathing about, for almost two years.

I was not suicidal but I wanted to be dead, at least dead to the experience of my own brain and body.

2015: I  began to recover after adding virgin coconut oil and organic grass-fed fed butter to a cup of instant coffee in the morning.

I did it hoping for mental acuity and better memory. After ten days of that, I was much better, mood-wise. Approximately neutral.

And, I experienced drowsiness. I could sleep. Not exactly happy, I did 30 days on Wellbutrin, because it had done me no harm in the past. 

I don't have the DAWS mood or state of mind. It never feel like doing anything if it means standing up.

In fact, I don't especially like moving. I'm a brain with a beanbag body.   :unsure:

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Where are the articles themselves?


I would not make any judgments about a paper based on the abstract. You have to read the entire paper.


Dr. Preskorn is probably the world's most prominent expert in drug-drug interactions and iatrogenic harm. I wouldn't assume evil intent, either.

This is not medical advice. Discuss any decisions about your medical care with a knowledgeable medical practitioner.

"It has become appallingly obvious that our technology has surpassed our humanity." -- Albert Einstein

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