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​Listen in as Dr Greg Mattingly and psychiatric nurse practitioner Michelle Shamblin share their clinical experiences with tardive dyskinesia and discuss best practices for tardive dyskinesia screening.

This podcast, “Screening for Tardive Dyskinesia: Best Practices in Person, Over Video, or via Telephone,” is a promotional educational program sponsored and co-developed by Neurocrine Biosciences and is not certified for continuing medical education. The speakers are presenting on behalf of and are paid consultants for Neurocrine Biosciences. The information presented is consistent with FDA guidelines.

Dr Mattingly: Welcome. This is Greg Mattingly coming to you from St Louis, Missouri, where I’m an associate clinical professor at Washington University School of Medicine and a practicing clinician here in St Louis. Today I’m going to talk about what I’ve seen with tardive dyskinesia as a researcher and clinician; but most importantly, I’m going to talk to you as someone who has a personal connection to tardive dyskinesia, because I have a family member who struggles with schizophrenia.

Ms Shamblin: And my name is Michelle Shamblin. I’m an adjunct professor at the University of Texas in Arlington, and I have a private practice as a psychiatric nurse practitioner in the Dallas-Fort Worth area. I am going to share with you my experience with tardive dyskinesia, including information about the prevalence of tardive dyskinesia and best practices for screening.

Dr Mattingly: How common is tardive dyskinesia?

Ms Shamblin: Well, it’s seen in about 5% to 30% of patients who are treated with antipsychotic medications.1 Most clinicians think to look for tardive dyskinesia in patients with schizophrenia, but there is a surprisingly large population who have tardive dyskinesia who have been treated with antipsychotics for mood disorders and anxiety disorders.2

Dr Mattingly: Michelle, I think one of the surprising things to many clinicians is that the majority of patients these days who have tardive dyskinesia may have an illness other than schizophrenia, like a complex mood disorder, a complex anxiety disorder, or posttraumatic stress disorder.2

Ms Shamblin: Greg, who do you suggest should be screened for tardive dyskinesia?

Dr Mattingly: I think anybody who is being treated with a dopamine-modulating medication needs to be screened for tardive dyskinesia.

Ms Shamblin: And who do you think are at the highest risk? What are some factors that would classify a person as being at a higher risk for tardive dyskinesia than others?

Dr Mattingly: So there are a lot of tardive dyskinesia risk factors. First of all, we have exposure to a medication that can lead to tardive dyskinesia, and exposure length correlates with someone’s risk.1,3-5 Some studies show women being at higher risk of tardive dyskinesia; some say if you’ve had a prior history of extrapyramidal side effects.3,4

Ms Shamblin: That’s interesting. I recently had a conversation with a 25-year-old woman who I’ve been treating for schizoaffective disorder for about 8 years with an antipsychotic. She isn’t showing any signs of tardive dyskinesia yet, but we had the conversation because she’ll be high risk. She’s White, she’s female, and she’s going to have lifelong exposure to antipsychotics.3,6

Dr Mattingly: Yeah, and other studies have shown that if you have a mood disorder, that may increase your risk.3,7 In my family’s case, we have a child who has an intellectual disability and is on an antipsychotic medication, and developmental disabilities have also been shown to increase risk.3 The 2020 American Psychiatric Association Practice Guideline for the Treatment of Patients With Schizophrenia includes these as potential risk factors for tardive dyskinesia.3

Dr Mattingly: So Michelle, how often would you screen your patients for tardive dyskinesia?

Ms Shamblin: Well, in actuality I observe my patients every time I see them to check if there are any abnormal movement disorders, but a formal screening with the Abnormal Involuntary Movement Scale exam, or AIMS, a very common and quick screener to run, is recommended at least once a year and preferably every 6 months.3,8

Dr Mattingly: So, what scales would you recommend to clinicians out there for tardive dyskinesia screening in addition to the AIMS?

Ms Shamblin: There are some others that are used less commonly, like the Dyskinesia Identification System Condensed User Scale, or DISCUS, and there are also some informal ways of just asking about symptoms. When talking to patients about their motor symptoms during an informal screen, it’s possible to get some information by asking targeted questions.

Ms Shamblin: Are there any reasons a patient would not want to talk to their health care provider about their tardive dyskinesia?

Dr Mattingly: In the case of tardive dyskinesia, there can be embarrassment caused by the movements.9 It can manifest as being embarrassed to be social, to eat with others, or even to go out in public. As clinicians, we should be a part of that journey and a part of seeing that journey improve.

Ms Shamblin: It’s important to know how far we’ve come. In the past we had no way of treating tardive dyskinesia. Patients who develop it can feel like they’re holding up a big card saying “I have a serious mental health issue” because long-term antipsychotic use is known to cause it.

I would also like to add that we really should assess people for the use of older antiemetics. I actually had a patient redevelop tardive dyskinesia when she had a bout of pancreatitis and was given a lot of the older antiemetic medications.

Dr Mattingly: So Michelle, how would you go about this during a telemedicine visit?

Ms. Shamblin: Well, I would start by trying to get as much of their body as possible in the frame on the screen.10 Unfortunately, they aren’t in the office physically, so I can’t watch them walk in and out of the waiting room; but having their body fill the screen helps. Sometimes if they have a caregiver with them, you can ask the caregiver to help out with this.

Ms Shamblin: So Greg, how do you ensure your telemedicine visits go smoothly?

Dr Mattingly: So the APA has a telemedicine toolkit that we can all use.11 Our patients can access it, we can access it, and they’re very practical tips. They break it up into things you should do before the visit, things you should do the day of the visit, and things you should do during the visit. And so before the visit, for example, you may want to send over some rating scales that your patients could fill out.

On the day of the visit, we want to make sure the patient goes online and checks that their internet connection’s working and they log into the correct portal about 10 to 15 minutes early.

Dr Mattingly: With that in mind, why don’t you share with us some of your experiences with telemedicine?

Ms Shamblin: Well, just a little bit ago I had an appointment with a patient who I had seen for years and who had been exposed to antipsychotics since childhood. One day I noticed when she laughed her tongue would stick out, and it would go in a rhythmic movement. I knew it was abnormal, but I didn’t know exactly what it was. I did send her to neurology to get a more definitive answer, and it was tardive dyskinesia. This shows that even through a telemedicine appointment, it is possible to notice these signs and flag anything that seems suspicious.

Ms Shamblin: So now that we’ve discussed how screening for tardive dyskinesia during video telemedicine appointments can work well, how can we ensure we have a successful telephone-only telemedicine visit?

Dr Mattingly: What we also know these days, Michelle, is that there are patients who lack access to technology to be able to have telemedicine visits via video platforms.12 Many patients want to or have to just use the phone, they may not have a good internet uplink, or they may be embarrassed. So we know that right now across the board it’s a question of “How do we deliver care, even without the visual component?” And so I look at the patient self-report rating scale and once again, you can even informally ask if your patient has noticed any movements. If the patient has a caregiver present, ask the caregiver if they’ve noticed any movements, as well. Also ask the patient if their movements affect their daily routine and physical functioning or impact them socially or emotionally.

Ms Shamblin: This was a lot of good information. Do you have any closing thoughts you want to make sure we get across to the audience before we wrap up this podcast?

Dr Mattingly: Thanks, Michelle. I want to make sure people know that by using standardized rating scales such as the AIMS when it’s available and other screening reports, it’s possible to find out what patients are experiencing and that there are ways to treat tardive dyskinesia.3,8 With the approval of recent treatments for tardive dyskinesia, we are in a position as clinicians where we can make a positive impact for our patients.

Ms Shamblin: Greg, that’s well said. I think my last takeaway would be that we need to be screening for tardive dyskinesia and abnormal movements in every patient taking an antipsychotic, antiemetic, or other dopamine-modulating drug.4,13,14

Please explore the other resources available on this website for more detailed information on identifying and diagnosing tardive dyskinesia.


References
1. Carbon M, Hsieh CH, Kane JM, Correll CU. Tardive dyskinesia prevalence in the period of second-generation antipsychotic use: a meta-analysis. J Clin Psychiatry. 2017;78(3):e264-e278.2. Loughlin AM, Lin N, Abler V, Carroll B. Tardive dyskinesia among patients using antipsychotic medications in customary clinical care in the United States. PLoS One. 2019;14(6):e0216044.
3. American Psychiatric Association. The American Psychiatric Association Practice Guideline for the Treatment of Patients with Schizophrenia. American Psychiatric Association; 2021.
4. Miller DD, McEvoy JP, Davis SM, et al. Clinical correlates of tardive dyskinesia in schizophrenia: baseline data from the CATIE schizophrenia trial. Schizophr Res. 2005;80(1):33-43.
5. Divac N, Prostran M, Jakovcevski, Cerovac N. Second-generation antipsychotics and extrapyramidal adverse effects. Biomed Res Int. 2014;2014:656370.
6. Woerner MG, Alvir JM, Saltz BL, Lieberman JA, Kane JM. Prospective study of tardive dyskinesia in the elderly: rates and risk factors. Am J Psychiatry. 1998;155(11):1521-1528.
7. Casey DE. Affective disorders and tardive dyskinesia. Encephale. 1988;14(Spec No):221-226.
8. Caroff SN, Citrome L, Meyer J, et al. A modified Delphi consensus study of the screening, diagnosis, and treatment of tardive dyskinesia. J Clin Psychiatry. 2020;81(2):19cs12983.
9. 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(3):259-268.
10. Treating TD in the COVID-19 era: 5 steps to success. Psychiatry & Behavioral Health Learning Network. June 8, 2020. Accessed December 9, 2020.
11. American Psychiatric Association. Learning to do telemental health. Accessed December 9, 2020. https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/toolkit/learning-telemental-health
12. American Psychiatric Association. Psychiatrists use of telepsychiatry during COVID-19 public health emergency. Policy recommendations. Accessed December 9, 2020. https://www.psychiatry.org/psychiatrists/practice/telepsychiatry
13. Fahn S, Jankovic J, Hallet M. The tardive syndromes: phenomenology, concepts on pathophysiology and treatment, and other neuroleptic-induced syndromes. In: Fahn S, Jankovic J, Hallet M, eds. Principles and Practice of Movement Disorders. 2nd ed. Saunders; 2011:415-446.
14. Lerner PP, Miodownik C, Lerner. Tardive dyskinesia (syndrome): current concept and modern approaches to its management. Psychiatry Clin Neurosci. 2015;69(6):321-334.