Background: Antipsychotic drugs have revolutionized the management of psychosis & other psychiatric illnesses. Unfortunately, incessant use of antipsychotics is increasing at an unprecedented rate in primary health care settings of developing countries like Bangladesh, without appropriate follow-up. Consequently, the rate of drug-induced extrapyramidal symptoms [EPS] is also on the rise, causing various distressing acute and delayed involuntary movement disorders. Four common EPS are recognized, namely parkinsonism, akathisia, dystonia, and tardive dyskinesia. Typical antipsychotics have a higher potential for inducing EPS. Elderly females are more prone to develop drug-induced parkinsonism and tardive dyskinesia. Treatment options, especially for akathisia and tardive syndromes, are often disappointing and frequently necessitate long-term palliative care. 

Objective: The case study aims to illustrate the distressful consequence of long-term antipsychotic drug use and emphasizes the rational use of these drugs with a thorough meticulous follow-up, even in primary health care settings.  

Case presentation: Shikha Rani Mondol, a 60-year-old  female, hailing from Madaripur village in Bangladesh, non-diabetic, hypertensive presented with repetitive involuntary movements of both upper and lower limbs, mouth, and eyes for the last 10 years. Eleven years ago, she was reasonably well until diagnosed with hypertension by a local physician. Prescribed antihypertensive medications and a combination of antipsychotic with antidepressant drug (Flupenthixol with Melitracen), she responded well, leading to a lack of routine follow-up visits and prolonged medication usage. Over the first 10 years patient gradually noticed spasms of different body parts which increased in severity over the last 5 years. Over the period she developed features of parkinsonism, namely blepharospasm, tremors, bradykinesia and other EPS-like dystonic features [torticollis] and dystonia of  right upper limb. Over the last 2 years, she also developed lip smacking (tardive dyskinesia), which was initially mild and then became extensive and persisted throughout the day. Gradually all the symptoms increased in severity and hampered her quality of life and daily activities. Consequently, she visited many physicians, and her management commenced accordingly. The antipsychotic drug, Flupenthixol with Melitracen, was discontinued and different anticholinergic drugs were introduced with different doses. However, she responded poorly to treatment. 

Conclusion: Prolonged use of antipsychotics, especially typical ones, may lead to debilitating extrapyramidal syndrome, often irreversible. The consequences may demand long-term palliative care, with related caring expenditures severely disrupting living standards. Hence, avoiding the irrational use of antipsychotics is crucial. Patients should undergo meticulous routine follow-up, even in primary care settings, for early detection of any complications of antipsychotic drugs.

Sabrina Momin is an Internist with 16 years of clinical experience in the arena of internal medicine. She graduated from Dhaka Medical College, Dhaka in 2008. After completing her MRCP degree in 2018 & FCPS[medicine] in 2022 she worked in different renowned Hospitals in Dhaka, Bangladesh. She is currently working as an assistant professor of internal medicine at MH Samorita Hospital and Medical College, Dhaka.

She is interested in Research, peer review, & scholarly publication. She has experience working as a visiting researcher in Kyushu University, Japan.

She is keen to attend many international conferences & courses worldwide, The most important ones are :

• Four days of extensive training in internal medicine at Renal Transplant Center, Chennai, India (Sundaram Medical Foundation) in 2017.

• 5th Conference of Asian Federation of Societies for Lactic Acid Bacteria, 1st-4th July, 2009, Singapore.

She is a member of BCPS[Bangladesh], RCP[UK] & MACP[USA]. She has an intense zeal for teaching and has been working as an MRCP instructor since 2018 and gathered about 6 years of post-graduation teaching experience to date. She has also started writing a book on medicine which is on the way to publication.