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eCase: TD Screening

CE / CME

eCase: Screening for TD: Not Just in Patients With Schizophrenia

Pharmacists: 0.50 contact hour (0.05 CEUs)

Physicians: Maximum of 0.50 AMA PRA Category 1 Credit™

Physician Assistants/Physician Associates: 0.50 AAPA Category 1 CME credit

Nurses: 0.50 Nursing contact hour

Released: February 28, 2022

Expiration: February 27, 2023

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Screening for TD in Patients Receiving Atypical Antipsychotic Treatment
Atypical antipsychotic use has expanded beyond chronic mental health conditions such as schizophrenia. Healthcare professionals now commonly prescribe atypical antipsychotics for bipolar disorder, augmentation of antidepressants, complex anxiety disorders, and developmental disabilities. Prescription statistics indicate that in 2020, just under one quarter of atypical antipsychotics were prescribed for schizophrenia, and prescriptions for bipolar disorder, major depression, and other conditions made up the rest.1 A similar review of 164,000 adults receiving atypicals in the United Healthcare/Optum database found that among individuals diagnosed with TD, the most common overlapping diagnoses were neurotic or anxiety disorders at 53%, mood disorders at 50%, and schizophrenia at 46%.2 Although TD is still highly prevalent among individuals with schizophrenia, the most common cases in a clinical practice may involve diagnoses other than traditional chronic psychotic illness.

Very few healthcare professionals were taught to routinely screen the wider variety of patients who now receive dopaminergic medications. The need to screen for TD and other medication-induced movement disorders is extremely important in patients with depression, bipolar disorder, anxiety disorders, and other psychiatric conditions for which they may be receiving atypical antipsychotic treatment.          

Risk Factors and Social and Emotional Impact of TD
Clearly, the use of an antipsychotic medication is a risk factor for the development of TD. Other risk factors associated with an increased vulnerability to developing TD include individuals older than 55 years of age; female sex; White or Black race/ethnicity; past or current extrapyramidal symptoms including akathisia, parkinsonism, or dystonic reactions; and presence of a mood disorder, intellectual disability, or central nervous system injury.3 In addition, a recent Veterans Affairs study showed that the use of the anticholinergic medication benztropine was associated with higher risk of the development of tardive dyskinetic movements.4

A recent study by McEvoy and colleagues5 highlights the social and emotional impact of TD. In total, 35% of participants in this study who had TD had a diagnosis of bipolar disorder, 34.5% had major depression, and 30.4% had schizophrenia. TD was associated with higher ratings of social withdrawal, worsened internalized stigma, and significantly lower ratings on overall quality of life. Patients became significantly more socially isolated and withdrawn as TD worsened.

The real-world impact of TD was recently explored by examining the social media posts of individuals with TD. Individuals were more likely to discuss the emotional aspects rather than the physical aspects of TD. Common terms used were “feel,” “worse,” “permanent,” “weird,” “horrible,” and “hate.”6

Where Do You Look for TD? Can Patients Screen for TD?
Recent studies have explored the utility of patient-rated screening tools compared with in-person physical examinations for detecting TD.7 Examinations by healthcare professionals found TD in the face, lips, and tongue in 66% of patients; hands and fingers in 59%; trunk in 21%; and lower limbs in 42%. In addition, more than 50% of patients had TD in 2 or more body regions. This study elucidates the importance of screening the entire body, not just focusing on the orofacial region.

This study also highlights that patients are aware of and can self-report their dyskinetic movements when asked. When patients were given a diagram of the body and asked whether they had experienced any abnormal movements in their head/face, neck/trunk, upper extremities, or lower extremities, patients were excellent self-reporters, showing high levels of correlation with clinical examination (P <.001).

With the FDA approval of 2 VMAT2 inhibitors for the treatment of TD, healthcare professionals now have options to improve the quality of life in individuals with TD. Pivotal trials of both deutetrabenazine and valbenazine allowed patients to stay on their antipsychotics, antidepressants, or mood stabilizers when warranted. Treatments with both of the approved VMAT2 inhibitors consistently have shown improvement in TD with minimal risk of worsening mood, psychosis, or other underlying psychiatric conditions.

References

  1. IQVIA National Prescription Adult Database. February 2020 - January 2021.
  2. Loughlin AM, Lin N, Abler V, et al. Tardive dyskinesia among patients using antipsychotic medications in customary clinical care in the United States. PLoS One. 2019;14:e0216044.
  3. American Psychiatric Association practice guideline for the treatment of patients with schizophrenia. 3rd edition. American Psychiatric Association; 2021.
  4. Caroff SN, Leong SH, Roberts CB, et al. Correlates of the abnormal involuntary movement scale in veterans with tardive dyskinesia. J Clin Psychopharmacol. 2020;40:373-380.
  5. McEvoy J, Gandhi SK, Rizio AA, et al. Effect of tardive dyskinesia on quality of life in patients with bipolar disorder, major depressive disorder, and schizophrenia. Qual Life Res. 2019;28:3303-3312.
  6. Farrar M, Lundt L, Franey E, et al. Patient perspective of tardive dyskinesia: results from a social media listening study. BMC Psychiatry. 2021;21:94.
  7. Caroff SN, Yeomans K, Lenderking WR, et al. RE-KINECT: a prospective study of the presence and healthcare burden of tardive dyskinesia in clinical practice settings. J Clin Psychopharmacol. 2020;40:259-268.

Which of the following is NOT a risk factor for tardive dyskinesia (TD)?
What would be the most appropriate next step if a patient receiving an antipsychotic medication develops TD?
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