To find more effective combinations for resistant and refractory tic disorders and to evaluate scheduled escalation of three drugs including high dose Vitamin B6 in psychiatric patients.

Twenty three adult patients (20 male, 3 female) with resistant Tourette syndrome were enrolled to this trial. They showed non compliance to different previous regimens including classic antipsychotics and newer dopamine/serotonin receptor antagonists. Mean age was 27yrs, global social functioning was impaired in all and substantially in 50%. Major depression and anxiety were encountered in 78 and 69% respectively as studied by way of MCMI-III and Hamilton.

After six weeks, twenty patients improved substantially with 80–90% reduction of abnormal movements as judged by the physician in charge and first degree relatives. Depression and anxiety also improved by at least 60% and global functioning improved much as patients felt better in work, social activities, parties and relation to the opposite sex. Maximal tolerated dose of the three drugs were 12.5, 40 and 400 mg respectively. Three patients exhibited extra pyramidal signs that responded to addition of Biperiden and 10 showed some numbness and dysphoria some times during treatment for which the doses were reduced. Most patients could maintain good functioning at lower doses of 5–7.5, 20 and 240 mg or less respectively.

We conclude that this combination in addition to scheduled escalation is extremely effective with enough compliance. Scheduled escalation causes better patients commitment as the drug increments planned and a necessity of treatment and not merely due to refractory disease.