The American Psychiatric Association recognizes several risk factors for TD, including long-term exposure to antipsychotic drugs, or APDs, mood disorder, substance use disorder, prior development of drug-induced parkinsonism, treatment for drug-induced parkinsonism with anticholinergics, age, and female sex. Thus, patients with mood disorders can have multiple risk factors for TD. For example, substance abuse is common in patients with mood disorders and confers additional risk for developing TD in patients with major depressive disorder and bipolar disorder.
The use of atypical APDs continues to rise, primarily driven by their use in the treatment of mood disorders. Although the prevalence of TD is lower with atypical agents, patients are still at risk and the increased use of these drugs is a significant contributor to the corresponding rise in the number of patients with TD. In a meta-analysis that examined the prevalence of TD, 1 in 14 patients without prior typical APD use had TD, compared with 1 in 3 patients treated with typical APDs. Additionally, 1 in 5 patients treated with atypical APDs, but with unknown previous exposure to typical agents, had TD.
In the United States, an estimated 41 million people suffer from depression and bipolar disorder. Many of these patients will receive long-term treatment with atypical APDs. Therefore, it is important for clinicians to recognize that these agents carry specific safety warnings not only for cardiovascular disease, neuroleptic malignant syndrome, and metabolic syndromes but also for development of TD. As mental health clinicians, we not only manage the brain, but we must also protect our patients’ hearts, be conscious of their metabolic health, and screen for development of TD.
The diagnosis of TD can be easily missed in patients with mood disorders, as movements from TD can manifest in a subtle manner and be perceived as minor or insignificant. However, the impact of even subtle TD on the patient can be severe. Small orofacial movements can result in changes in speech and painful biting of the cheeks and tongue. TD can also be a source of embarrassment, leading to the avoidance of social encounters and cause patients to become reclusive.
Patients with mood disorders may often be high functioning, live active lives, and have greater sensitivity to even mild movements when compared with schizophrenia patients, who frequently lack the same degree of insight. TD movements, no matter how subtle, can undermine the stability of a patient’s mood disorder, resulting in worsening of their mental health.
Patients with TD who are undiagnosed far outnumber those who are diagnosed. Even when diagnosed, only a small percentage receive appropriate treatment with a vesicular monoamine transporter 2, or VMAT2, inhibitor. This, in part, may be the result of missing TD symptoms or misdiagnosing them as another type of movement disorder. Fortunately, there are protocols that can help clinicians recognize and assess TD.
Every clinical encounter should be used as an opportunity to visually screen patients and ask them if they have experienced any involuntary movements. If there is suspicion of TD, clinicians should more formally evaluate the patient’s movements using the Abnormal Involuntary Movement Scale, or AIMS. AIMS, a 12-item scale scored from 0 to 4, is widely used to screen for and monitor TD symptoms, measure the overall severity of symptoms, and assess the global impact of TD on the patient. A minimum score of 2 on any AIMS items 1-7 confirms TD movements and justifies assessing the impact of TD on the patient. Performing an AIMS examination is uncomplicated and should be part of the standard mental health professional tool kit.
Explaining to patients why they have developed TD can be difficult. Educating patients is essential to help them make informed treatment decisions as they may not understand that TD is an iatrogenic disease resulting from exposure to APDs. It is important for clinicians to have an open dialogue with their patients when initiating treatment with an atypical APD, to make them aware that, although low, there is a chance of developing TD. Encouraging patients to ask questions can improve clinician-patient relationships. Patients should know that they will be periodically assessed, and if they develop TD, they can be treated with a VMAT2 inhibitor.
Patients may often feel overburdened with their current treatment regimens or may have an emotional reaction to the abnormal movements they are experiencing and may not want to receive treatment for TD. TD movements initially tolerated by patients at diagnosis can begin to impact new aspects of their lives over time and shift their desire to initiate treatment. During patient follow-up appointments, clinicians should continue to assess and discuss the impact of TD on the patient and reoffer appropriate treatment.
Motivational interviewing techniques can also help clinicians address treatment hesitancy by highlighting the challenges they face, prompting them to reconsider their stance, and supporting the achievement of their goals. Clinicians can encourage patients to consider how they would advise others facing similar challenges, emphasizing the importance of treatment in improving their symptoms.
Polypharmacy regimens for neuropsychiatric patients are now more the rule than the exception. With each additional medication added to a patient’s treatment regimen their risk for drug-drug interactions increases. Clinicians should consider the metabolic pathways of the concomitant medications and select a VMAT2 inhibitor that is appropriate for each specific patient. AUSTEDO XR has no contraindications for use with medications that are strong CYP3A4 inducers or inhibitors and has 5 doses up to 36 mg/day that may be used concomitantly with strong CYP2D6 inhibitors.
It is important for clinicians to understand that each patient can be titrated to a specific dose that suitably manages their TD. AUSTEDO XR is available in a one pill, once-daily treatment option that provides clinicians the flexibility to choose a dose that is effective and achieves tolerable symptom control.
It is essential for clinicians to realize that APDs are, increasingly, a routine choice for clinicians treating patients with mood disorders. The use of these agents creates a clinical dilemma as atypical APDs still carry the risk of causing TD. Therefore, it is crucial to have a discussion with patients and assess movements at every clinical encounter. Even subtle movements of TD can affect patients with mood disorders, as these individuals often lead active lives, are highly functional, and are more aware of and sensitive to involuntary movements. It is important to maintain a high index of suspicion in these cases and take the time to thoroughly screen for TD and evaluate its impact on patients so that clinicians can make appropriate treatment decisions for their patients.
