Quetiapine-Related Tardive Dyskinesia

Ms. A, a 25-year-old woman with type I bipolar disorder, was seen in consultation. She had been diagnosed and treated for bipolar disorder for the previous 4 years with combinations of mood stabilizers, anticonvulsants, and atypical antipsychotic agents. She had never taken typical neuroleptic medications. Among her previous medications were lithium, carbamazepine, divalproex sodium, lamotrigine, fluoxetine, bupropion, gabapentin, and topiramate. She took olanzapine for 1 month but discontinued it because of weight gain. She took risperidone for less than 1 week, discontinuing it because she developed a rash. She received quetiapine as an alternative to olanzapine when the latter was discontinued.

The indication for treatment was persistent rapid-cycling mood episodes despite concomitant treatment with gabapentin, 4400 mg/day, and lithium, 900 mg/day. Ms. A’s quetiapine dose was gradually increased to a maintenance dose of 125 mg/day. Repetitive involuntary jaw movements were noticeable within 6 weeks of the initiation of quetiapine treatment and persisted despite a decreased dose. Quetiapine was discontinued after 13 weeks of treatment because of the jaw movements. Ten months after the initiation of quetiapine Ms. A’s mild repetitive involuntary lower jaw movements remained. Her mood symptoms had improved with 4400 mg/day of gabapentin, 900 mg/day of lithium, and 200 mg/day of topiramate. No other involuntary movements were noted.