"In my practice, I tell my patients taking antipsychotic medications about the possibility of developing TD from the first visit, and I assess for TD symptoms at every visit after they start antipsychotic treatment."

Rakesh Jain, MD, MPH

"Every patient with any exposure to dopamine D2 receptor blocking medications should be screened informally for any abnormal movements at each visit, and then at appropriate intervals using a scale such as the Abnormal Involuntary Movement Scale (AIMS). The informal examination and the formal AIMS examination — both involve eliciting information from a patient and/or their support system in addition to objective observations."

Rakesh Jain, MD, MPH

"All patients taking D2 receptor blocking agents, including antipsychotics, should be screened for TD at baseline and every visit subsequently. Some patients have additive risk factors that evoke a higher likelihood of developing TD, but all patients need to be tracked appropriately. Sometimes, patients come into my practice on medications that may be inappropriately used for TD, such as anticholinergics, and for these patients I may need to thoroughly evaluate and consider changes to their existing medication regimen."

Gustavo Alva, MD, DFAPA

"In cases where the patient is treatment naïve to antipsychotic therapy, or even just new to the practice setting, regardless of age, I think it's important to complete a structured movement disorder assessment to establish a baseline. I also think it's important to ensure that those responsible for conducting structured assessments are well trained and are able to demonstrate consistency with others on staff so that ratings are reliable. This minimizes the potential variance that can occur through the use of multiple raters."

Steve Stoner, RPh, PharmD, BCPP

"In my clinical practice the standard is to do a clinical assessment to screen for TD every time I see a patient at risk for TD. The goal is to catch TD early on, if possible, because of the impact TD can have on patients. With early detection, I can offer appropriate interventions to manage TD. Even for patients who have been living with TD for many years — if not decades — assessment and identification is still key to monitor for any new or potential impact/impairment that TD may be having on the patient. One tool I find helpful in clinical assessment of TD, whether face to face, via telemedicine, or even over the telephone, is the MIND-TD Questionnaire."

Desiree Matthews, PMHNP-BC

"Telehealth visits are common today, and I expect them to be a significant component of clinician-patient interactions for the foreseeable future. This is, however, no reason for clinicians to abdicate our responsibility to conduct both informal and formal examinations for the emergence of any abnormal movement disorders."

Rakesh Jain, MD, MPH

"Ideally patients should be seen in person when diagnosing TD. However, screening can be accomplished via telehealth, as well. Even if a telephonic encounter is the only avenue available, the use of in-depth questioning can carry the day in starting the process of discovering TD. In rank order, live, video, and then telephonic assessments are doable. Interspersing in-person encounters as best as possible is advisable."

Gustavo Alva, MD, DFAPA

"Screening for TD through telehealth visits is possible, though it does require being able to meet the patient where they are in terms of technical skills and what electronic devices they have at their disposal. Something that practices can consider as an alternative to telehealth is expanding the scope of who can conduct abnormal movement assessments. Patients have to go to a physical location to receive their long-acting injectable medications, whether it be a pharmacy or community mental health center. Ensuring that pharmacists and nurses are trained to conduct movement disorder assessments can expand the concept of a 'touch point' for the patient because they will have contact with a provider in some capacity to receive their medication, and an assessment can be done easily at the time of the injection."

Steve Stoner, RPh, PharmD, BCPP

"In my clinical experience, I find that I am usually able to identify movements consistent with TD during video appointments — the key is to keep your eyes and ears open to possible TD during assessment. Look and ask about possible involuntary movements that may be consistent with TD. Also, do not forget that you may need to get creative and recruit resources on hand to assist with the assessment! I have had success with patients — care partners being the camera person and I am the director — I direct where the camera needs to focus on so I can get an accurate head-to-toe assessment."

Desiree Matthews, PMHNP-BC

"I endeavor to educate my residents and fellows regarding TD by informing them of its significant presence in our caseloads. I also advise them of the potential negative psychosocial impact of this condition. I then inform them on how to best use the AIMS and how to educate patients about their new diagnosis, should they be first diagnosed by the residents and fellows. And finally, I educate them about the FDA-approved options available to treat this condition and how to best optimize treatment to achieve an ideal balance between efficacy and tolerability for each individual patient."

Rakesh Jain, MD, MPH

"The best approach to diagnosing TD is to think beyond the chief complaint that the patient walks in with. If we limit ourselves to scrutinizing the underlying neuropsychiatric condition and don't keep our eyes open, we'll never diagnose someone who could be impacted by TD."

Gustavo Alva, MD, DFAPA

"In making a diagnosis of TD, I think it's important to look at the whole picture that is in front of you. This means learning the patient's history, their prior medications as well as their current medications, and identifying any relevant medical history that may contribute to involuntary movements. It's also important to identify known risk factors for TD. Once this information is collected, you can complete a drug-induced movement disorder assessment, such as an AIMS exam. You may also need to differentiate TD from other drug-induced movement disorders, such as drug-induced parkinsonism. From there, it's a lot of practice and comparing your findings with your colleagues, to refine your skills at both symptom identification and severity ratings."

Steve Stoner, RPh, PharmD, BCPP

"In my clinical experience, I always assess adherence to their antipsychotic treatment to rule out neuroleptic withdrawal dyskinesia that could look like TD movements! That is the most common differential diagnosis that I encounter in my personal practice."

Desiree Matthews, PMHNP-BC

"For the majority of my patients with TD, I don't find it necessary to seek a neurology consultation. However, in some situations it is prudent to seek an opinion from a specialist, especially when the diagnosis is uncertain or the patient clearly has multiple types of movement difficulties, such as concurrent TD and parkinsonism. It's worth reemphasizing that, in the vast majority of my patients with TD, psychiatry professionals have the competence to manage this disorder very well."

Rakesh Jain, MD, MPH

"When I see patients with coexisting parkinsonian symptoms and TD symptoms, I refer them to a neurologist who specializes in movement disorders. Outside of that, I have not generally needed to make referrals."

Gustavo Alva, MD, DFAPA

"I have sought neurology consults when the 'picture' I am seeing does not add up with the information I have as it relates to medication history or other health history and there are no known risk factors for TD. I have also asked for neurology consultation when there would appear to be a clear and obvious case of TD, but it doesn't seem to respond in a manner that you would expect with treatment interventions."

Steve Stoner, RPh, PharmD, BCPP

"Recently, I referred a patient who I suspect might have TD of the diaphragm. Symptoms included patient's report of new onset of involuntary gasping for breath, but there were no other clues to possible TD other than his work up and treatment history with dopamine receptor blocking agents. The work up from his primary care and ENT were negative/inconclusive. During the exam, I was unable to detect any visual movements of his diaphragm through the abdominal wall nor was I able to observe the 'gasping' for air he was reporting. The patient reported significant distress and fear associated with these episodes. I decided to refer him for consult with a neurologist experienced in movement disorders."

Desiree Matthews, PMHNP-BC

"Multiple factors go into the creation of a treatment plan once a patient is diagnosed with TD. All of these factors come into play — patient preference for treatment, severity of TD, impairment from TD (taking a biopsychosocial approach to elucidating any impairment), affordability and access to treatment, and finally, a patient's level of disease understanding and motivation to change. When all of these factors align, I then gently offer a realistic but optimistic picture of what improvement would most likely look like. Patients appreciate such a combination of realistic but optimistic expectation setting and are then ready for a discussion about treatment options."

Rakesh Jain, MD, MPH

"So long as confidentiality isn't breached, I try to converse with as many family members and caregivers involved in the patient's care as I can to educate them about TD and discuss goals and expected treatment outcomes."

Gustavo Alva, MD, DFAPA

"The majority of my practice has been in the forensic setting. The discussion should certainly involve the patient and the guardian, if they have one assigned. If abnormal movements are identified, it is important to conduct a thorough medication history and review of prior documentation and treatments. In addition, it's important to determine the patient's level of awareness, determine if the movements are debilitating or impairing their function in any way, and identify how long the symptoms of TD have been present and if any behaviors have been modified because of the movements. Based on these factors, treatment for TD can be discussed once the diagnosis of TD is made."

Steve Stoner, RPh, PharmD, BCPP

"When it comes to offering treatment for TD, focus on impact and the impairment that TD may cause now or, potentially, in the future. I use motivational interviewing techniques to help uncover patients - thoughts and feelings about TD. I also interview the care partner, if applicable. Often, the care partner will bring up possible impact and impairment that the patient may be unaware of or even embarrassed to bring up with me. Ultimately, I offer my patients treatment as medically appropriate for all cases of TD based on patient preference, any moderate to severe TD, or if patients are reporting impact/impairment included with activities of daily living and emotional well-being."

Desiree Matthews, PMHNP-BC

"In my experience, follow-up visits are crucial to track and optimize outcomes with TD and to enhance adherence. During follow-up visits, I recommend asking open-ended questions to solicit information about improvements and challenges with TD since the last visit. I also explore current adherence to see if it needs to be improved upon; assess the current treatment and see if it needs to be optimized; and use motivational interviewing techniques to ensure optimum adherence to therapy. It is important for us clinicians to appreciate that some patients who receive a TD diagnosis may be frightened and confused. Therefore, proactively exploring and addressing such issues during follow-up visits is important."

Rakesh Jain, MD, MPH

"Realistic expectations are at the heart of success. It is imperative for patients to understand their TD diagnosis; their treatment, if applicable; the expected outcomes of said treatment; and the interplay that might exist between TD and their broader mental well-being."

Gustavo Alva, MD, DFAPA

"The majority of my work has been in a forensic, long-term care, inpatient setting. When patients are admitted, they are evaluated for drug-induced movement disorders, which helps to establish a baseline. My personal preference has always been to evaluate patients who have drug-induced movement disorders and for whom we are changing medications more frequently. In the long-term care setting, this usually means monthly evaluation until we see some degree of improvement or stabilization that would allow for more time between formal standardized assessments, whether that be 3-, 6-, or 12-month intervals."

Steve Stoner, RPh, PharmD, BCPP

"When following up with a patient with a new diagnosis of TD, I always discuss prognosis and the given literature about TD. I also explore possible treatment goals referring to common themes that they may have brought up during visits, such as embarrassment about uncontrolled movements or an inability to complete certain daily tasks. In some cases, patients may not want to start treatment immediately and will be assessed/monitored at each visit for potential worsening of symptoms or impact/impairment complaints. If the patient and care partners choose to start TD treatment, an AIMS score will be obtained as a baseline, and we will discuss treatment expectations, including how long it might take to work, dosing, and potential side effects. Upon follow-up after starting treatment for TD, I will reassess movements using the AIMS and, most importantly, follow up on the patient's treatment goals. Many of my patients start treatment due to an identifiable concern about the current or potential impact on their daily activities or broader mental well-being. I always follow up to see if there have been improvements in their areas of concern."

Desiree Matthews, PMHNP-BC