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Contents lists available at ScienceDirect

Asian Journal of Psychiatry

journal homepage: www.elsevier.com/locate/ajp

Evaluating the effect of risperidone on speech: A cross-sectional study

Preeti Sinha a,1, V.P. Vandana b,*, Nikita Vincent Lewis b,2, M. Jayaram b,3, Pamela Enderby c
a
Department of Psychiatry, National Institute of Mental Health and Neurosciences, Hosur Road, Bangalore 560029, Karnataka, India
b
Department of Speech Pathology and Audiology, National Institute of Mental Health and Neurosciences, Hosur Road, Bangalore 560029, Karnataka, India
c
The Innovation Centre, 217 Portobello, Sheffield S1 4DP, UK

A R T I C L E I N F O A B S T R A C T

Article history: Speech subsystems are susceptible to the effects of several factors including medications. The atypical
Received 7 November 2014 antipsychotics can also adversely affect the speech because of its action on serotonin and dopamine
Received in revised form 9 April 2015 neurotransmitters. The present study aims to analyze the speech characteristics associated with atypical
Accepted 3 May 2015
antipsychotic risperidone. Speech of 92 patients on risperidone with or without trihexyphenidyl and/or
Available online xxx
clonazepam were compared with that of 31 persons who were not on any psychotropic medicines.
Compared to control group, maximum phonation duration, sequential motion rate of diadochokinesia
Keywords:
was reduced by about 3 s and 1 syllable/s respectively and s/z ratio was increased by 0.16 in patients
Risperidone
with risperidone. Performance of larynx, lips and tongue sub-system and intelligibility of speech were
Atypical antipsychotics
Speech also significantly reduced in risperidone group. Risperidone did impact the phonation and articulation
Articulation sub-systems of speech mildly, which was independent of tardive dyskinesia and extrapyramidal
Phonation symptoms. Randomized controlled prospective study looking into impact on speech and related effect on
Adverse-effects drug adherence, functioning and quality of life needs to be conducted with risperidone and other atypical
antipsychotics.
ß 2015 Elsevier B.V. All rights reserved.

hence, may affect the process of speech. Antipsychotic drugs are

1. Introduction
one of them and it acts on neurotransmitters; primarily
dopamine; which plays a role in neuromuscular control
Speech is a complex task involving the coordinated action of
(Haddad and Sharma, 2007).
different muscles including muscles of lips, jaw, tongue, soft
People with psychosis have poor quality of life (Solanki et al.,
palate, pharynx and larynx as well as muscles of respiration
2008) and high degree of self-stigma (Brohan et al., 2010).
(Murdoch, 1998). The corresponding sub-systems of speech are
Considering that speech difficulties may also cause decrease in
respiration, phonation and articulation. Medications used to
functioning and quality of life (Klompas and Ross, 2004; Craig et al.,
treat neurological and psychiatric disorders may cause distur-
2009), it becomes pertinent to pay attention on the speech of
bance in neuromuscular control of these sub-systems and
patients on antipsychotics. Most of the available information is
limited to problems in speech musculature secondary to TD
Abbreviations: AMR, alternating motion rate; DDK, diadochokinesia; EPS, extrapy- (Gabbert et al., 2002). Perioral and lingual dyskinesia (up to 72% of
ramidal symptoms; FDA, frenchay dysarthria assessment; MDVP, multidimensional TD) (Hemmati et al., 2010) are more prone to cause speech
voice parameters; MFF, maximum fundamental frequency; MPD, maximum difficulties. The patient may make sucking/kissing/smacking/
phonation duration; NHR, noise harmonic ratio; SAS, Simpson–Angus Scale; clicking noises, or may have dysphagia, dysfluency or effect on
SMR, sequential motion rate; TD, tardive dyskinesia.
one of the speech subsystems. Detailed speech evaluation of
* Corresponding author. Tel.: +91 80 26995758; mobile: +91 8277645059.
E-mail addresses: drpreetisinha@gmail.com (P. Sinha),
27 patients on long-term antipsychotics by Khan et al. (1994)
vpvandana@gmail.com (V.P. Vandana), nikkivlewis@gmail.com (N.V. Lewis), claimed that all speech deficits were secondary to tardive
jayaram@nimhans.kar.nic.in (M. Jayaram), dyskinesia, particularly oro-facial dyskinesia and there is no direct
m.enderby@sheffield.ac.uk">p.?m.enderby@sheffield.ac.uk (P. Enderby). role of antipsychotic (Khan et al., 1994). However, the number of
1
Tel.: +91 80 26995273; mobile: +91 9243328988.
2 patients without tardive dyskinesia (10 out of 27) in the study may
Permanent address: Speech Therapist, Applied Behavior Center, Burj Jassim,
Kuwait. not be adequate for detecting relatively less common adverse
3
Tel.: +91 80 26995569. effects on speech. Hence the direct effect of antipsychotic drugs on

http://dx.doi.org/10.1016/j.ajp.2015.05.005
1876-2018/ß 2015 Elsevier B.V. All rights reserved.

Please cite this article in press as: Sinha, P., et al., Evaluating the effect of risperidone on speech: A cross-sectional study. Asian J.
Psychiatry (2015), http://dx.doi.org/10.1016/j.ajp.2015.05.005
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2 P. Sinha et al. / Asian Journal of Psychiatry xxx (2015) xxx–xxx
speech production could have been missed. Besides, the drugs
prescribed in this study were typical antipsychotics. Tardive
dystonia also had been reported to cause speech deficits, although,
mostly had TD along with and hence, it is difficult to ascertain its
contribution (Gabbert et al., 2002).
With better efficacy and tolerability (Leucht et al., 2013),
atypical antipsychotics are preferred than typical antipsychotics.
They are also supposed to have lesser impact on speech because
of lesser incidence of EPS (Leucht et al., 2013) and TD (Dolder
and Jeste, 2003). But, people have not investigated it formally.
Only available literature are case reports and case series.
Risperidone is one among them. There are case reports on
risperidone induced stuttering (Lee et al., 2001; Yadav, 2010). At
the same time, there are small trials (Maguire et al., 2000) and
case reports (Ranjan et al., 2006; Tavano et al., 2011) which
favor risperidone use in the treatment of stuttering. Risperidone
induced dysphagia is also reported as case reports where it
improved either after risperidone discontinuation (Stewart,
2003; Brahm et al., 2007) or after addition of benztropine (Nair
et al., 2001).
To conclude, communication deficits can add to poor quality of
life and perceived self-stigma in patients on risperidone. Currently,
the information available for its impact on the speech system is
limited to case reports without explicit details of speech
subsystems involvement. Due to different adverse-effect profile,
it is not reasonable to take inference about risperidone from the
present literature of movement disorder’s related speech abnor-
malities caused by typical antipsychotics. Hence, this study was
carried out with the objectives to compare speech production in
patients on risperidone to that of normal population using acoustic
and perceptual measures of speech and to identify associated
clinical and treatment characteristics.
2. Methods
2.1. Participants
In the 1st group, 92 participants in the age range of 20–60 years
(mean age = 35.51 years, SD = 10.22) who were prescribed
risperidone were recruited for the study. All the participants
were on a stable regimen of risperidone for a minimum duration of
3 months for mental illness diagnosed by a psychiatrist at
NIMHANS. Those having concurrent administration of medica-
tions other than benzodiazepine or trihexyphenidyl were
excluded. The presence of tardive dyskinesia was actively looked
for and those who had mild or more degrees of movements in
any area according to Abnormal Involuntary Movement Scale
(AIMS) (Lane et al., 1985) were also excluded. The other group was
of 31 normal participants who were matched in age to the
participants were recruited for the study (mean age = 35.65 years,
SD = 10.45). None of them were on antipsychotic or other
medications and have not been reported to have any psychiatric
illness. Each participant in 2nd group was selected for four
participants in 1st group.
All participants in both groups were either Kannada, Hindi or
English speaking. Those having any speech impediment on brief
history or had co-morbid problems likely to cause speech
difficulties such as intellectual disability, autism, attention deficit
hyperactive disorder, seizures and any potential neurological
disorder were not recruited for either of the two groups. Patient
who had speech difficulties before the initiation of medication
were excluded. Informed consent was taken from the participants
prior to administration of tests, after explaining the aims and
nature of tests. The study protocol was approved by the Institute
Ethics committee.
Please cite this article in press as: Sinha, P., et al., Evaluating the effect of risperidone on speech: A cross-sectional study. Asian J.
Psychiatry (2015), http://dx.doi.org/10.1016/j.ajp.2015.05.005
2.2. Procedure
The study was conducted as evaluation in one visit. The three
main sections of evaluation were assessment of speech skills
and acoustic part of speech, a dysarthria rating scale and
assessment of EPS.
The first section included a detailed assessment of respiration,
phonation and articulation subsystems of speech. The MPD task is
an informal measure of respiratory–laryngeal system function.
The participants were instructed to phonate the vowels /a/ as
long as possible at a comfortable loudness level after taking a
deep inhalation. Three trials were given for the vowel. The mean
duration of the three trials was considered as maximum
phonation duration for/a/. The other task was s/z ratio which
indicates the laryngeal pathology by taking the ratio of time taken
to sustain the consonant /s/ to that of consonant /z/ in one breath.
The best of three attempts is recorded in both tests (Aronson and
Bless, 2009).
In order to evaluate articulation, DDK rate tasks as iterations
per second were used. It involves AMR (defined as the rapid
repetition of a single syllable /pa/, /ta/ or /ka/) and SMR (defined
as the rapid repetition of a syllable sequence such as /pataka/).
They were to repeat these sounds as rapidly and precisely as
possible on a single breath. The order of production of the four
DDK tasks was maintained the same for all subjects (/pa/, /ta/, /
ka/ & /pataka/) (in order to maintain uniformity). Two trials for
each of these tasks were given and samples recorded (Tjaden and
Watling, 2003).
The Computerized Speech Laboratory (CSL) – 4300 (Kay
Elemetrics) software was used to do objective acoustic analysis
of vowel phonation sustained for at least 3 s. The MDVP which
were assessed here were jitter (%), shimmer (%), NHR and MFF (in
Hertz). They belong to the groups of frequency perturbation,
amplitude, Noise related and fundamental frequency parameters
respectively (Kent et al., 2003; Gamboa et al., 1998).
All participants were tested individually and audio samples
were recorded onto the multidimensional voice profile in the
computerized speech laboratory (Model – 4400) with an external
microphone placed 10 cm away from the mouth of the patient.
Analysis of phonatory parameters was done at a sampling rate of
44.1 kHz. The calculation algorithms for each parameter were
preset. The sample size of 3 s in the midportion of the phonation
was considered. This was done to capture relative stable effort and
pitch in the sample of the subjects and to control the effects due to
phonation – onset and phonation – offset (Kent et al., 1999). Each
participant was provided with a 2 min break between assessments.
The audio recordings were saved and later analyzed. Scoring was
done according to the instructions provided with each scale
described above.
We employed Frenchay Dysarthria Assessment, FDA – 2nd
Edition (Enderby and Palmer, 2008) for second section. It includes
seven sections that comprised of reflex, respiration, lips, palate,
laryngeal, tongue and intelligibility. The person is asked to use
these structures in various usual functions of them including
speech. Each item within the sections was rated on 10-point rating
scale (0–9) and total score for each sections as well as the final
score was reached by averaging them. Further assessment of
dysphagia and stuttering was planned to be done only if above said
evaluation and/or subjective complaints indicated the same.
The presence of EPS, if any, in participants of risperidone group
and its degree was assessed using the Simpson–Angus Scale, SAS
(Simpson and Angus, 1970). Each of its 10 items is rated using a
5-point scale (0–4). The total scores can range from 0 to 40 and the
mean score is obtained by dividing the total scores by 10. The cut-
off for antipsychotic induced EPS was kept as mean score of 0.65
(Janno et al., 2005).
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P. Sinha et al. / Asian Journal of Psychiatry xxx (2015) xxx–xxx 3

Table 1 3. Results
Age and gender distribution among all three groups.

Sub-group Risperidone group Control group There were 92 participants in risperidone group, and 31 parti-
frequency (% of total) frequency (% of total) cipants in control group. There was no significant difference
20–30 years 34 (36.9%) 10 (32.3%) between the groups in age or gender distribution (Table 1).
31–40 years 29 (31.5% 11 (35.5%) The comparison of speech data and FDA findings between
41–60 years 29 (31.5%) 10 (32.3%) risperidone and control group are covered in Tables 2 and 3. The
Total 92 31 significant differences were noted in the scores of Lips, Tongue, and
Males 42 (45.6%) 15 (48.6%) Larynx subsections of FDA, FDA-total, MPD, s/z ratio, AMR and
Females 50 (54.4%) 16 (51.4%) SMR. None of the participants who had complaints of dysphagia
and no significant difference was found in FDA-reflex assessment
between the two groups. Similarly, none of them was found to have
stuttering. Hence, detailed assessment of dysphagia or stuttering
2.3. Statistical analysis was not performed.
The categorical as well as continuous distribution of dose and
In order to compare the speech parameters between risperi- duration of risperidone and mean SAS score assessing EPS in the
done group and control group, t-test with assessing equality of risperidone group are shown in Table 4. The Pearson correlation
variances with Levene’s test was performed for normally coefficients of mean SAS score, dose and duration of risperidone
distributed variables and Mann–Whitney test was performed for with various speech parameters ranged between 0.38 and
parameters which were not normally distributed. For maximum 0.203. However, in categorical distribution of same, the group of
fundamental frequency, we compared data of men and women Antipsychotic induced EPS was found to have higher NHR
separately among risperidone and control group. The association of (p = 0.016) and increased MFF in females (p = 0.020). MFF in
dose and duration of risperidone and EPS with speech parameters females was similarly found to be increased in participants with
in risperidone group was assessed by Kruskal Wallis test/Mann– risperidone only (p = 0.031) compared to those took both risperi-
Whitney U-test for ordinal variables and Pearson correlation for done and trihexyphenidyl. There were 82 patients (89%) who were
scale variables. The threshold for statistical significance was kept on trihexiphenidyl concurrent to risperidone. The group compari-
at a p value < 0.05 son for benzodiazepine (10 patients, 11%) as the grouping variable

Table 2
Comparison of normally distributed speech parameters between risperidone and control group with t-test.

Speech tasks Risperidone group mean (SD) Control group mean (SD) Mean difference (SE) p value (2-tailed)

Maximum fundamental frequency (Hz) (males) 129.12 (17.39) 134.58 (20.37) 5.4 (5.07) 0.286
Maximum fundamental frequency (Hz) (females) 217.37 (37.71) 199.21 (45.63) 18.16 (12.62) 0.157
Jitter (%) 1.74 (2.17) 1.13 (0.73) 0.61 (0.26) 0.124
Shimmer (%) 3.54 (2.44) 3.11 (1.14) 0.44 (0.33) 0.186
Noise to harmonic ratio 0.57 (2.7) 0.14 (0.06) 0.43 (0.28) 0.130
FDA-reflex 8.31 (0.72) 8.45 (0.46) 0.13 (0.14) 0.228
FDA-respiration 8.34 (0.62) 8.42 (0.46) 0.08 (0.12) 0.412
FDA-lips 8.21 (0.61) 8.48 (0.53) 0.27 (0.12) 0.020
FDA-palate 8.82 (0.32) 8.90 (0.28) 0.07 (0.06) 0.222
FDA-intelligibility 8.70 (0.44) 8.86 (0.27) 0.16 (0.07) 0.021

Table 3
Comparison of non-normally distributed speech parameters between risperidone and control group with Mann–Whitney U-test.

Speech tasks Risperidone group mean (SD) Control group mean (SD) p value (2-tailed)

Maximum phonation duration (s) 10.80 (3.94) 13.77 (3.30) <0.001

s/z ratio 1.21 (0.22) 1.04 (0.08) <0.001
Sequential motion rate (syllables/s) 6.66 (1.09) 7.45 (0.83) <0.001
Alternate motion rate (syllables/s) 4.63 (0.82) 4.93 (0.75) 0.050
FDA-larynx 7.98 (0.81) 8.75 (0.36) <0.001
FDA-tongue 8.18 (0.72) 8.61 (0.46) <0.001
FDA-total 8.36 (0.37) 8.63 (0.18) <0.001

Table 4
Distribution of dose and duration of risperidone, and EPS in ‘‘risperidone’’ group.

Category Frequency (%) Variable Mean (SD)

Low dose (4 mg/day) 65 out of 92 (70.7%) Dose in mg/day 4.6 (2.26)
High dose (>4 mg/day) 27 out of 92 (29.3%)
Duration (<1 year) 39 out of 92 (42.4%) Duration in months 24.4 (35)
Duration (1–2 years) 37 out of 92 (40.2%)
Duration (>2 years) 16 out of 92 (17.4%)
Antipsychotic induced EPS present (mean SAS score > 0.65) 6 out of 92 (6.5%) Mean SAS score 0.19 (0.24)
Antipsychotic induced EPS absent (mean SAS score  0.65) 86 out of 92 (93.5%)

Please cite this article in press as: Sinha, P., et al., Evaluating the effect of risperidone on speech: A cross-sectional study. Asian J.
Psychiatry (2015), http://dx.doi.org/10.1016/j.ajp.2015.05.005
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4 P. Sinha et al. / Asian Journal of Psychiatry xxx (2015) xxx–xxx
was not performed because all of them were on trihexiphenidyl as
well. The shimmer % varied from 0.4% to 1.1% between participants
who received risperidone for 1 year, between 1 and 2 years and
more than 2 years (p = 0.02).
4. Discussion
The study aimed to assess the nature of speech disorders, if any,
associated with the use of risperidone, compared to control
population. This is the first study which tried to look into the effects
of any atypical antipsychotic on speech beyond the boundaries of
case series.
The difference was evident in respiratory–laryngeal and
articulatory systems of the speech. Reduced scoring of MPD
(Aronson and Bless, 2009; Hirano et al., 1968) and laryngeal section
of FDA indicates inadequate respiratory–laryngeal function in
participants on risperidone. The laryngeal pathology was further
supported by increased s/z ratio in risperidone group and might be
caused by defective vocal fold vibration and resulting glottal
insufficiency (Eckel and Boone, 1981). DDK, and lips and tongue
sub-system of FDA were deficient in risperidone group, thus points
toward the possible deficiency in articulation (Kent et al., 1987;
Duffy, 2012). The rapid shifts of action and inhibition of articulatory
muscles and sustained action of one group of articulatory muscles
as indicated by SMR and AMR of DDK respectively may be affected
by risperidone. All these are speculations as this study is first of its
kind analyzing the effect of atypical antipsychotic drugs on speech
production. Further studies in this regard are needed to establish
them. The intelligibility which gets affected by articulation as well as
respiration and phonation also showed marginal variation between
the risperidone and control group as well as the overall scoring of
dysarthria.
Tardive dyskinesia due to typical antipsychotics is reported to
be associated with respiratory–laryngeal and articulatory muscles
(oro-facial) involvement (Gabbert et al., 2002; Hemmati et al.,
2010; Feve et al., 1995; Bick, 1983; Menuck, 1981). A detailed
evaluation in 27 male patients found reduced MPD, intelligibility of
speech and rate of speech (indicated here with SMR) in those with
tardive dyskinesia compared to those without tardive dyskinesia
(Khan et al., 1994). Our study had similar differences but with
lesser degree of differences (reduction in MPD – 6 s vs 3 s,
intelligibility – 30% vs 3%, rate of speech – 15% vs 10%). Thus,
antipsychotics may affect speech independent of tardive dyskine-
sia in similar fashion although with lesser degree. The other
important variations from that study were more detailed and
objective assessment of speech, larger sample size and comparison
with control group in our study. Case reports (Gabbert et al., 2002)
of rythmless speech or strangled voice with stridor and related
breathing difficulties as reported with antipsychotics secondary to
tardive dyskinesia were not noted in our study.
With atypical antipsychotics, most of the available literature
are the case reports of speech dysfluency, i.e. stuttering (Lee et al.,
2001; Yadav, 2010; Bär et al., 2004) and dysphagia (Stewart, 2003;
Sagar et al., 2005). None of the participants in our study were found
to have them as subjective complaints or on objective evaluation.
Thus, stuttering and dysphagia may not be common speech related
adverse-effects of atypical antipsychotics and more likely to be
appearing if there is associated tardive dyskinesia (Lyall et al.,
2007; Varghese et al., 2006), tardive dystonia (Duggal and
Mendhekar, 2008), myoclonus (Duggal et al., 2002; Supprian
et al., 1999) (in case of clozapine), old age (Stewart, 2003) or
developmental disability (Brahm et al., 2007).
As expected from distribution of concurrent administration of
trihexyphenidyl (82 out of 92 participants) in risperidone group,
very few participants (6.5%) had antipsychotic induced EPS and
hence, may not be responsible for the difference in speech
Please cite this article in press as: Sinha, P., et al., Evaluating the effect of risperidone on speech: A cross-sectional study. Asian J.
Psychiatry (2015), http://dx.doi.org/10.1016/j.ajp.2015.05.005
components between risperidone and control group observed in
this study. This was further confirmed by correlation analysis.
Nevertheless, MFF in females and noise to harmonic ratio were
distinctly higher in group with antipsychotic induced EPS which
would be perceived as hoarse or harsh voice and high pitch voice
respectively. Thus EPS may play a role in quality of voice and affect
vocal cord vibrations. It also matches partly to speech findings of
Parkinson disease (Kent et al., 2003; Tanaka et al., 2011).
There was a statistically significant increase in shimmer %
among various sub-groups as the duration of risperidone
treatment increased from less than 1 year to more than 2 years.
Although this increase in shimmer % may not lead to hoarseness of
voice in most cases, such patients may be more predisposed for
vocal cord pathology, especially in professional voice users.
Besides shimmer %, we did not find association of any speech
deficit with high dose or long duration of risperidone. These
results need to be interpreted with caution because of unequal
numbers of participants in each sub-group. The case reports did
report appearance or increase of speech adverse-effects with
increase in dose of atypical antipsychotics (Yadav, 2010; Lyall
et al., 2007; Krishnakanth et al., 2008).
The degree of deficits which was noted in various areas of
speech with risperidone in our study was milder. The following
factors might have contributed to it. It was a cross-sectional study
of patients who are maintained on risperidone for at least
3 months. The case reports available in the literature illustrate
speech difficulties in the initial phase of starting antipsychotics. It
is likely that this study would have missed the population who had
changed or stopped the medications due to the distress caused by
moderate to severe speech difficulties. Most of the patients in
risperidone group were on trihexyphenidyl and hence, it was
difficult to rule out the role of trihexyphenidyl on speech outcome.
In terms of speech evaluation, addition of sentence or conversa-
tional level analysis would have given better idea of articulation
deficits. Besides, the presence of speech production difficulties
before the initiation of risperidone was ruled out only through
history and hence we might have missed subtle pre-medication
speech difficulties.
Benign voice problems are also reported to cause substantial
impact on individual and can have negative consequences on
professional, social, psychological aspects of individual (Smith
et al., 1996). This effect on daily functional activities is also
influenced by individual perception, reaction and adjustment to
the problem (Ma and Yiu, 2001). The information on how to reduce
or prevent aggravation of voice problems (such as reduced vocal
demand, reduced environmental noise, vocal misuse and vocal
hyperfunction) are helpful for affected individuals, especially
professional voice users (Mattiske et al., 1998; Chan, 1994). Thus,
the minor speech problems found in this study should not be
neglected and requires further interrogation of its impact on
already compromised quality of life of patients on antipsychotics
due to their underlying psychotic illness. These speech deficits are
also likely to increase the self-stigma present in such patients and
should be explored further. We need to keep them in mind
particularly in cases where communication and speech is a part of
his or her professional requirements.
To summarize, the speech of risperidone group did differ from
that of the control group in the areas of phonation and articulation
which was independent of tardive dyskinesia and EPS and also was
not limited to high dose or longer duration of intake to risperidone.
The quality of phonation as assessed with objective acoustic
analysis was not much affected. However, the same was more
affected in risperidone group who had EPS and hence, the areas to
be focused for speech problems in those have EPS may not be
similar to those who do not have EPS and need further exploration.
These findings need to be confirmed with other atypical
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antipsychotics and with randomized controlled prospective study.
The future studies should also focus on the course and impact of
such speech deficits in various functional and psychological
dimensions, drug adherence, and the improvement with possible
interventions.
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