Prophylaxis of antipsychotic-induced extrapyramidal side effects in east Indians: cultural practice or biological necessity?

OBJECTIVE: Although still controversial, as early as 1989, the World Health Organization recommended that antipsychotic agents should be initiated without routinely adding anticholinergic drugs prophylactically. However, combined treatment with antipsychotics and anticholinergic agents is the norm in India. The goal of this study was to investigate whether Indians are more susceptible to extrapyramidal side effects (EPS) or if the practice of routinely adding an anticholinergic agent to an antipsychotic is overly cautious and wasteful. METHOD: 75 consecutive patients started on conventional antipsychotics were repeatedly evaluated over 2 months on a standardized EPS scale, the abbreviated Simpson-Angus scale. RESULTS: Of 71 subjects who completed the study, 68 (96%) suffered EPS while receiving 2-13 mg/day of haloperidol equivalents, with 70% of EPS present by day 5 and 90% by day 10. The most common symptoms were tremor (49%), cogwheel rigidity (40%), and acute dsytonic reaction (34%). Routine clinical care detected 49% of the EPS, patients volunteered a complaint 19% of the time, and relatives reported EPS in 7% of patients. CONCLUSION: Since patients of Indian origin are prone to suffer EPS when taking conventional antipsychotic drugs, initial prophylaxis with antiparkinson agents should perhaps be more carefully considered on a routine basis. Even among atypicals, agents with the least potential to cause EPS should be favored. In all patients treated with antipsychotics, it is imperative to ask directly about and carefully examine for EPS, because few patients will volunteer their complaints.