CQAIMH - center for quality assessment and improvement in mental health



Bipolar Disorder: Monitoring for extrapyradmidal symptoms


This measure assesses the percentage of patients diagnosed with bipolar disorder and treated with an antipsychotic agent who were assessed for the presence of extrapyramidal symptoms twice within the first 24 weeks of treatment.

Clinical Rationale:

Extrapyramidal Symptoms

  • Extrapyramidal symptoms refer to movement disorders that occur when there is a disruption of the brain’s extrapyramidal system.  Extrapyramidal Symptoms are referred to as EPS (1,5)
  • EPS neurological side effects include akathisia, a motor restlessness, and muscle rigidity and tremor, which are sometimes referred to as drug-induced Parkinsonian symptoms (1,4,5)
  • EPS also includes tardive dyskinesia and acute dystonia, rare but severe side effects that also relate to disruption of the extrapyramidal system. Sometimes these symptoms are referred to as distinct side effects due to their severity (1,4,5)

Extrapyramidal Symptoms and Antipsychotic Agents

  • Typical antipsychotics are associated with significant acute neurologic side effects (1,3)
  • Tardive dyskinesia (TD) is the principal adverse effect of long-term typical  (first generation) antipsychotic treatment; however, studies indicate that TD still occurs with atypical (second generation) antipsychotic agents (5) 
  • Atypical (second generation)  antipsychotics have been reported to have a lower rate of EPS, particularly acute dystonia and drug-induced Parkinsonism (2)

Monitoring for Extrapyradmidal Symptoms

  • Patients with bipolar disorder should be regularly monitored for iatrogenic adverse effects of antipsychotic medication including extrapyramidal symptoms (4)
  • Regular examination for early signs of tardive dyskinesia is an appropriate monitoring plan (5)

Denominator Population:

Patients diagnosed and treated for dipolar disorder with an antipsychotic agent

Data Sources:

  • Administrative data
  • Medical Record

Numerator Population:

Patients assessed for extrapyradmidal symptoms (EPS) twice during initial 24 weeks of treatment

Data Source:

  • Medical Record

Initial Case-finding Guidance:

Patients with a diagnosis involving bipolar disorder
ICD9CM or DSM IV TR: 296.0x; 296.1x; 296.4x; 296.5x; 296.6x; 296.7; 296.80-82; 296.89; or 301.13

STABLE Resource Toolkit:

The following instruments are recommended by the STABLE National Coordinating Council for use in assessing extrapyramidal symptoms.  The tools are available in the corresponding section of the STABLE Resource Toolkit.

  • Abnormal Involuntary Movement Scale (AIMS): Clinician tool used to assess tardive dyskinesia. 
  • Antipsychotic Symptom Checklist (ASC): Captures adverse effects of antipsychotic agents


  1. Wirshing W, Movement disorders associated with neuroleptic treatment. J. Clin Psychiatry 2001; 62 (Suppl.21): 15-18
  2. Miller D, Yatham L, Lam R, Comparative efficacy of typical and atypical antipsychotics as add-on therapy to mood stabilizers in the treatment of acute mania. J Clin Psychiatry 2001; 62: 975-980
  3. Keck PE, Perlis R, Otto M, Carpenter D, Ross R, Docherty J, Treatment of Bipolar Disorder 2004; The Expert Consensus Guideline Series, Postgraduate Medicine, A Special Report, December 2004
  4. Yatham LN, Kenned, SH, et al.; Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines for the managements of patients with bipolar disorder: consensus and controversies, Bipolar Disorders 2005: 7(Suppl. 3): 5-69
  5. Tarsy D, Baldessarini R, Epidemiology of Tardive Dyskinesia: Is Risk Declining with Modern Antipsychotics?, Movement Disorders Vol 21, No 5, 2006, 589-598

Copyright 2007 by the Center for Quality Assessment and Improvement in Mental Health