psychiatrist

This work may not be copied, distributed, displayed, published, reproduced, transmitted, modified, posted, sold, licensed, or used for commercial purposes. By downloading this file, you are agreeing to the publisher’s Terms & Conditions.

eReport

Diagnostic and Treatment Fundamentals for Tardive Dyskinesia

Christoph U. Correll, MDa, and Leslie Citrome, MD, MPHb

Published: October 12, 2021

Tardive dyskinesia (TD) consists of involuntary movements of the tongue, lips, face, trunk, and extremities that occur in patients treated long-term with dopamine antagonist medications. TD can be associated with significant functional impairment and be socially stigmatizing. TD, once established, has proved to be often irreversible and remains a significant treatment issue. An accurate and early diagnosis of TD is crucial because the risk of permanence increases over time. Clinicians should be educated on which patients are most at risk for TD and conduct assessments through clinical examination or through the use of a structured evaluative tool such as the Abnormal Involuntary Movement Scale (AIMS). Patients and caregivers need to be educated about the risks of and alternatives to antipsychotic medication and early signs of TD. New treatment approaches to persistent TD are available and approved by the US Food and Drug Administration: the vesicular monoamine transporter-2 (VMAT2) inhibitors, deutetrabenazine and valbenazine. When treatment is initiated, a baseline assessment should be obtained by clinicians using the AIMS and follow-up assessments should be done on a regular basis. In this educational activity, Drs Correll and Citrome offer a review of the diagnostic and treatment fundamentals for TD.

This CME activity is expired. For more CME activities, visit CMEInstitute.com.
Find more articles on this and other psychiatry and CNS topics:
The Journal of Clinical Psychiatry
The Primary Care Companion for CNS Disorders

Can you recognize risk factors for tardive dyskinesia? Are you familiar with diagnostic criteria? Do you regularly assess patients for the condition? Are you knowledgeable about using new medications for TD? Experts share best practices for the assessment and treatment of TD.

From the Series: Revisiting the Fundamentals of Diagnosing and Treating Tardive Dyskinesia
To cite: Correll CU, Citrome LL. Diagnostic and treatment fundamentals for tardive dyskinesia. J Clin Psychiatry. 2021;82(6):NU20016AX1C.
To share: https://doi.org/10.4088/JCP.NU20016AX1C
© Copyright 2021 Physicians Postgraduate Press, Inc.

CME Background Information

Target Audience

Psychiatrists, neurologists, primary care clinicians, and psychiatric nurse practitioners and physician assistants

Support Statement

Supported by an educational grant from Neurocrine Biosciences, Inc.

Learning Objectives

After completing this educational activity, you should be able to:

  • Evaluate patients for TD per recommendations
  • Select the most appropriate TD treatment strategy for each patient

Release, Review, and Expiration Dates

This CME activity was published in September 2021 and is eligible for AMA PRA Category 1 Credit™ through September 30, 2023. The latest review of this material was August 2021.

Statement of Need and Purpose

TD must be detected early to minimize the risk of the movements becoming permanent. But many clinicians are unable to identify risk factors for this condition, are unfamiliar with diagnostic criteria, and do not regularly assess patients for TD. Clinicians, therefore, need education on the risk factors that should alert them to monitor certain patients especially closely for TD and strategies to assess all patients being treated with dopamine-blocking agents and provide an accurate diagnosis. In addition, while treatment for TD is available, with evidence-based recommendations and research on long-term safety and efficacy, clinicians may be slow to implement treatment strategies due to underestimation of the social and occupational impact that TD has on patients’ lives and uncertainty about what to do.

Disclosure of Off-Label Usage

Dr Correll has determined that, to the best of his knowledge, Vitamin E, Vitamin B6, Ginkgo Biloba, eicosapentaenoic acid (fish oil), melatonin, clonazepam, amantadine, donepezil, Branched Chain Aminoacids (BCAA), reserpine and tetrabenazine, are not approved by the US Food and Drug Administration for the treatment of tardive dyskinesia.

Review Process

The faculty members agreed to provide a balanced and evidence-based presentation and discussed the topics and CME objectives during the planning sessions. The faculty’s submitted content was validated by CME Institute staff, and the activity was evaluated for accuracy, use of evidence, and fair balance by the Chair and a peer reviewer who is without conflict of interest.

Acknowledgment

This activity is derived from the teleconference series “Revisiting the Fundamentals of Diagnosing and Treating Tardive Dyskinesia,” which was held in March 2021 and supported by an educational grant from Neurocrine Biosciences, Inc. The opinions expressed herein are those of the faculty and do not necessarily reflect the opinions of the CME provider and publisher or the commercial supporter.

Faculty Affiliation

Christoph U. Correll, MD
Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York; Charité Universitätsmedizin Berlin, Germany

Leslie Citrome, MD, MPH
New York Medical College, Valhalla

Financial Disclosure

The faculty for this CME activity and the CME Institute staff were asked to complete a statement regarding all relevant personal and financial relationships between themselves or their spouse/partner and any commercial interest. The Accreditation Council for Continuing Medical Education (ACCME) defines a commercial interest as any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. The ACCME defines relevant financial relationships as financial relationships in any amount occurring within the past 12 months that create a conflict of interest. The CME Institute has resolved any conflicts of interest that were identified. No member of the CME Institute staff reported any relevant personal financial relationships. Faculty financial disclosure is as follows:

Dr Citrome is a consultant for AbbVie, Acadia, Alkermes, Allergan, Avanir, Axsome, BioXcel, Cadent Therapeutics, Eisai, Impel, Intra-Cellular Therapies, Janssen, Karuna, Lundbeck, Luye, Merck, Neurocrine, Noven, Osmotica, Otsuka, Sage, Shire, Sunovion, Takeda, and Teva; is a member of the speakers/advisory boards for AbbVie, Acadia, Alkermes, Allergan, Eisai, Intra-Cellular Therapies, Janssen, Lundbeck, Merck, Neurocrine, Noven, Otsuka, Sage, Shire, Sunovion, Takeda, Teva; is a stock shareholder of Bristol-Myers, Squibb, Eli Lilly, J&J, Merck, and Pfizer; and has received royalties from Wiley, UpToDate, Springer Healthcare, and Elsevier.

The Chair for this activity, Dr Correll, has received grant/research support and honoraria from Acadia, Alkermes, Allergan, Angelini, Axsome, Gedeon Richter, Gerson Lehrman Group, Indivior, IntraCellular Therapies, Janssen/J&J, Karuna, LB Pharma, Lundbeck, MedAvante-ProPhase, MedInCell, Medscape, Merck, Mitsubishi Tanabe Pharma, Mylan, Neurocrine, Noven, Otsuka, Pfizer, Recordati, Rovi, Servier, Sumitomo Dainippon, Sunovion, Supernus, Takeda, and Teva; has received grant/research support from Janssen and Takeda; is a member of the speakers/advisory boards for Acadia, Alkermes, Allergan, Angelini, Axsome, Gedeon Richter, IntraCellular Therapies, Janssen/J&J, LB Pharma, Lundbeck, MedInCell, Merck, Mylan, Neurocrine, Noven, Otsuka, Pfizer, Recordati, Rovi, Servier, Sumitomo Dainippon, Sunovion, Supernus, Takeda, and Teva; and is a stock shareholder of LB Pharma.

Accreditation Statement

The CME Institute of Physicians Postgraduate Press, Inc., is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Credit Designation

The CME Institute of Physicians Postgraduate Press, Inc., designates this enduring material for a maximum of 1.00 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Note: The American Nurses Credentialing Center (ANCC) and the American Academy of Physician Assistants (AAPA) accept certificates of participation for educational activities certified for AMA PRA Category 1 Credit™ from organizations accredited by the ACCME.

To obtain credit for this activity, study the material and complete the CME Posttest and Evaluation.

References

ASPX – Initiating Coverage Of Auspex Pharmaceuticals: A Potential Blockbuster For Movement Disorders With Phase 3 Data Soon. Zacks SCR. November 12, 2014. https://s27.q4cdn.com/906368049/files/ASPX_Initiation-Report-November-2014_Napodano_v001_s99jj4.pdf

Bernstein AI, Stout KA, Miller GW. The vesicular monoamine transporter 2: an underexplored pharmacological target. Neurochem Int. 2014;73:89–97. PubMed CrossRef

Bhidayasiri R, Fahn S, Weiner WJ, et al; American Academy of Neurology. Evidence-based guideline: treatment of tardive syndromes: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2013;81(5):463–469. PubMed CrossRef

Carbon M, Hsieh C-H, Kane JM, et al. Tardive Dyskinesia Prevalence in the Period of Second-Generation Antipsychotic Use: A Meta-Analysis. J Clin Psychiatry. 2017;78(3):e264–e278. PubMed CrossRef

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. PubMed

Caroff SN, Hurford I, Lybrand J, et al. Movement disorders induced by antipsychotic drugs: implications of the CATIE schizophrenia trial. Neurol Clin. 2011;29(1):127–148, viii. PubMed CrossRef

Caroff SN, Miller DD, Dhopesh V, et al. Is there a rational management strategy for tardive dyskinesia? Curr Psychiatr. 2011;10(10):22–32.

Citrome L, Dufresne R, Dyrud JM. Tardive Dyskinesia: Minimizing Risk and Improving Outcomes in Schizophrenia and Other Disorders. Am J Manag Care Suppl. 2007;12(1):1–12.

Citrome L. Clinical management of tardive dyskinesia: Five steps to success. J Neurol Sci. 2017;383:199–204. PubMed CrossRef

Citrome L. Consider a ‘medical food’ for tardive dyskinesia. Curr Psychiatr. 2014;13(5):24.

Citrome L. Food and Drug Administration-Approved Treatments for Acute Bipolar Depression: What We Have and What We Need. J Clin Psychopharmacol. 2020;40(4):334–338. PubMed CrossRef

Citrome L, Saklad SR. Revisiting tardive dyskinesia: focusing on the basics of identification and treatment. J Clin Psychiatry. 2020;81(2):TV18059AH3C. PubMed CrossRef

Cloud LJ, Zutshi D, Factor SA. Tardive dyskinesia: therapeutic options for an increasingly common disorder. Neurotherapeutics. 2014;11(1):166–176. PubMed CrossRef

Dyskinesia Identification System, DISCUS Rating Form (revised). State of Connecticut Department of Mental Retardation. https://portal.ct.gov/-/media/DDS/Health/hcsma20002b.pdf

Factor SA, Remington G, Comella CL, et al. The effects of valbenazine in participants with tardive dyskinesia: results of the 1-year KINECT 3 extension study. J Clin Psychiatry. 2017;78(9):1344–1350. PubMed CrossRef

Fernandez HH, Factor SA, Hauser RA, et al. Randomized controlled trial of deutetrabenazine for tardive dyskinesia: The ARM-TD study. Neurology. 2017;88(21):2003–2010. PubMed CrossRef

Fernandez HH, Stamler D, Davis MD, et al. Long-term safety and efficacy of deutetrabenazine for the treatment of tardive dyskinesia. J Neurol Neurosurg Psychiatry. 2019;90(12):1317–1323. PubMed CrossRef

Goldberg JF. Determining Patient Candidacy for Antidepressant Use in Bipolar Disorder. Psychiatr Ann. 2019;49(9):386–391. CrossRef

Guy W. Abnormal Involuntary Movement Scale (AIMS). ECDEU Assessment Manual for Psychopharmacology. DHEW Publication No. 76-338. Rockville, MD: National Institute of Mental Health; 1976:534–537.

Hauser RA, Factor SA, Marder SR, et al. KINECT 3: A Phase 3 Randomized, Double-Blind, Placebo-Controlled Trial of Valbenazine for Tardive Dyskinesia. Am J Psychiatry. 2017;174(5):476–484. PubMed CrossRef

Jankelowitz SK. Treatment of neurolept-induced tardive dyskinesia. Neuropsychiatr Dis Treat. 2013;9:1371–1380. PubMed CrossRef

Kaspar R, Ellingrod VL. Strategies for managing drug-induced tardive dyskinesia. Curr Psychiatr. 2014;13(3):44–46.

Keepers GA, Fochtmann LJ, Anzia JM, et al. Practice Guideline for the Treatment of Patients With Schizophrenia. 3rd ed. American Psychiatric Association Publishing; 2021.

Keepers GA, Fochtmann LJ, Anzia JM, et al. STATEMENT 14: VMAT2 Medications for Tardive Dyskinesia. Practice Guideline for the Treatment of Patients With Schizophrenia. 3rd ed. American Psychiatric Association Publishing; 2021:113–118.

Kim J, Macmaster E, Schwartz TL. Tardive dyskinesia in patients treated with atypical antipsychotics: case series and brief review of etiologic and treatment considerations. Drugs Context. 2014;3:212259. PubMed CrossRef

Kraepelin EL. Der Psychiatre. 7th German ed. London: McMillian; 1907.

Leung JG, Breden EL. Tetrabenazine for the treatment of tardive dyskinesia. Ann Pharmacother. 2011;45(4):525–531. PubMed CrossRef

Mentzel TQ, van der Snoek R, Lieverse R, et al. Clozapine monotherapy as a treatment for antipsychotic-induced tardive dyskinesia: a meta-analysis. J Clin Psychiatry. 2018;79(6):17r11852. PubMed CrossRef

Miller BJ, Davis MC, Mathis MV. In Pursuit of Tardive Dyskinesia: The Breakthrough Designation and Approval of Valbenazine. US Food & Drug Administration; September 19, 2017. https://www.fda.gov/drugs/news-events-human-drugs/pursuit-tardive-dyskinesia-breakthrough-designation-and-approval-valbenazine

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. PubMed CrossRef

Müller T. Valbenazine granted breakthrough drug status for treating tardive dyskinesia. Expert Opin Investig Drugs. 2015;24(6):737–742. PubMed CrossRef

O’Brien CF, Jimenez R, Hauser RA, et al. NBI-98854, a selective monoamine transport inhibitor for the treatment of tardive dyskinesia: A randomized, double-blind, placebo-controlled study. Mov Disord. 2015;30(12):1681–1687. PubMed CrossRef

Schonecker M. Paroxysmal dyskinesia as the effect of megaphen [in German]. Nervenarzt. 1957;28(12):550–553. PubMed

Shen V, Clarence-Smith K, Hunter C, et al. Safety and Efficacy of Tetrabenazine and Use of Concomitant Medications During Long-Term, Open-Label Treatment of Chorea Associated with Huntington’s and Other Diseases. Tremor Other Hyperkinet Mov (N Y). 2013;3(0):tre-03-191-4337-1. PubMed CrossRef

Solmi M, Pigato G, Kane JM, et al. Treatment of tardive dyskinesia with VMAT-2 inhibitors: a systematic review and meta-analysis of randomized controlled trials. Drug Des Devel Ther. 2018;12:1215–1238. PubMed CrossRef

Stevens JR. Pathophysiology of schizophrenia. Clin Neuropharmacol. 1983;6(2):77–90. PubMed CrossRef

Teva Announces Breakthrough Therapy Designation for SD-809 Granted by FDA for the Treatment of Tardive Dyskinesia. Teva. November 9, 2015. https://www.tevapharm.com/news-and-media/latest-news/teva-announces-breakthrough-therapy-designation-for-sd-809-granted-by-fda-for-the-treatment-of-tardive-dy/

Ward KM, Citrome L; Tardive Dyskinesia-Key Differences in Pathophysiology and Clinical Management. Antipsychotic-Related Movement Disorders: Drug-Induced Parkinsonism vs. Neurol Ther. 2018;7(2):233–248. PubMed CrossRef

Volume: 82

Quick Links:

References

RECENT ARTICLES
ORIGINAL RESEARCH
Maxwell F. Lydiatt and others

EDITORIAL FOCUS
CASE REPORT
Melissa Vaz-Ayes and others

CASE REPORT
Vincent Zhang and others

ACADEMIC HIGHLIGHTS
Jordan F. Karp and others