On the Front Line: Helping Advanced Practice Providers to Recognize, Assess, and Treat Tardive Dyskinesia

Approximately 1 in 4 adults in the United States experiences a mental illness.¹ At the same time, there has been a decrease in the number of psychiatrists, underscoring the importance of a robust workforce of healthcare professionals, including psychiatric-mental health advanced practice providers (APPs), composed of nurse practitioners (NPs) and physician assistants (PAs).^2,3 This article provides mental health APPs with an overview of tardive dyskinesia (TD), a movement disorder resulting from exposure to antipsychotic drugs.⁴ It also explores the multifaceted impact of TD on patients’ lives.

In 2023, it was estimated that approximately 59 million US adults, or 23% of the adult population, experienced a mental illness, and nearly half of those individuals did not receive treatment.¹ Mental healthcare clinicians can range from psychiatrists, psychologists, NPs, and PAs to social workers, and from solo practitioners to multidisciplinary teams.^5-7

Compounding this crisis is a growing shortage of psychiatrists, with projections from the US Health Resources and Services Administration (HRSA) predicting a deficit of 18,000 to 21,000 professionals by 2030, suggesting that an expanding number of people of all ages will have unmet behavioral health needs.^1,2 Due to this accelerating demand for mental healthcare professionals, NPs and PAs are an increasingly vital resource for managing patients with mental health disorders.³ According to the HRSA, 11,310 new NPs and PAs are expected to join the workforce by 2030, highlighting the essential role of these providers in meeting the rising demand for mental healthcare and mitigating the shortage of psychiatrists.⁸

Dopamine receptor blocking agents such as atypical and typical antipsychotics are commonly used to treat a variety of psychiatric disorders. It is known that they may cause side effects, including movement disorders such as TD, drug-induced parkinsonism (DIP), akathisia, and dystonia.⁹

TD is a persistent, typically irreversible, hyperkinetic movement disorder that affects approximately 785,000 individuals in the US.^4,10,11 Despite this prevalence, TD may be underdiagnosed and undertreated, with approximately 15% of patients receiving a formal diagnosis and less than 6% being treated with vesicular monoamine transporter 2 (VMAT2) inhibitors, the only FDA-approved treatments for TD.^11-13 While TD primarily affects the face, it can also impact any part of the body, including the trunk and extremities (Video 1).¹⁴

Patient images used with permission.

According to an online survey of patients, TD can hinder a clinician’s ability to manage a patient’s underlying mental health condition.¹⁵

• 48% reported they skipped doses of an antipsychotic medication or took less than the doctor instructed
• 39% reported they stopped taking antipsychotic medication altogether
• 36% stopped going to the doctor for treatment of their underlying condition
• 21% advised someone else not to take an antipsychotic medication

One of the challenges in assessing the impact of TD on patients is that the clinician’s perception of mild movements may not equal the patient’s experience of impact.¹⁶ The disconnect between movement severity, as observed by the clinician, and impact, as experienced by the patient, is illustrated in Videos 2 and 3 below.

Patient images used with permission.

Any presentation of TD can have a profound impact on various aspects of patients’ lives such as their capacity to carry out daily tasks, maintain productivity, and engage in social activities.^17-19 TD manifestations such as these can complicate the management of the underlying mental health disorder.²⁰

Historically, it was believed that the severity of TD movements dictated the overall impact on the patient. However, more recently it has become evident that movement severity is only part of the equation, and TD can have a broader impact on patients’ lives.²¹ To more fully comprehend the impact of TD, the IMPACT-TD Registry study was established to systematically collect data across various domains of patients’ lives. This study was the first of its kind, and its objective was to significantly enhance the understanding of TD.²²

A key finding from this interim analysis was that patients with symptoms that were considered mild, based on measurements taken by a healthcare professional, can experience a moderate to severe impact of TD. Notably, this study revealed that 54% of patients with very mild or 61% with mild TD (based on the Clinical Global Impression of Severity of TD) experienced a moderate to severe impact on the clinician IMPACT-TD global score. Furthermore, approximately 74% of patients with an Abnormal Involuntary Movement Scale (AIMS) score of 1 to 6 reported moderate to severe impact from TD.¹⁶

Additionally, the impact of movements extended into the social, psychological, physical, and vocational/educational/recreational dimensions of patients’ lives, with 83% indicating moderate to severe impact in at least 1 domain.¹⁶ Patients have reported that TD had an impact on the following²³

• ~60% said their movements prevented them from leaving the house
• >75% reported feeling embarrassed in social situations
• >60% said movements impacted their sleep
• >50% reported their movements limited them at work

Presented below are testimonials from patients conveying the impact of TD in their own words across various domains studied in the IMPACT-TD Registry study (Videos 4-7).

Patient images used with permission.

Managing patients treated with antipsychotics involves not only screening for and assessing TD movements but also understanding the wider impact TD has on patients, their families, and caregivers.^24-26 There may also be a discrepancy between the severity of movements observed by the clinician and the impact as experienced by the patient.¹⁶ Thus, it is essential to look for any abnormal movements and ask questions to gauge the impact of these movements at every clinical encounter (Figure).^18,24,27,28

Figure. In all patients with current or previous exposure to antipsychotics^{4,18, 25,29}

Per American Psychiatric Association (APA) Guidelines, VMAT2 inhibitors are recommended if TD has an impact on the patient, regardless of the severity of movements.²⁵

• Amid the mental health crisis and psychiatrist shortage in the US, the demand for mental healthcare professionals is growing^1-3
• Psychiatric mental health NPs and PAs have a critical role in filling this gap³
• In recent years, the number of antipsychotic prescriptions has increased, resulting in an increased prevalence of TD, a hyperkinetic and often irreversible movement disorder^4,10,11
• Data from the groundbreaking IMPACT-TD Registry study shows that TD movements, regardless of severity, can impact patients across the social, psychological, physical, and vocational/educational/recreational aspects of their lives¹⁶
• Assessment of TD impact should be performed at every clinical visit²⁴
• The APA Guidelines support treatment of TD that has an impact on the patient with VMAT2 inhibitors, regardless of severity of movements²⁵