Tardive dyskinesia: Out of the shadows

The approvals of the first two medications, valbenazine and deutetrabenazine, to treat tardive dyskinesia have ushered in a new era in neuropsychiatric care. Tardive syndromes are defined as delayed onset, persistent movement disorders or sensory phenomena that occur in association with exposure to dopamine receptor blocking agents (DRBAs). Their underlying pathophysiology remains to be fully elucidated, but clinicians can conceptualize tardive syndromes as persistent dopamine supersensitivity states. Tardive syndromes can potentially cause distress, disfigurement, embarrassment, and dysfunction, and are often permanent. Therefore, practitioners who prescribe DRBAs should be aware of this potential, carefully assess the risk/benefit ratio when considering the use of these medications, and be sure that patients are appropriately informed. Patients on DRBAs should be monitored for the development of tardive syndromes, including through the use of regularly scheduled Abnormal Involuntary Movement Scale (AIMS) (or similar) examinations. Clinicians prescribing DRBAs should be familiar with the diagnosis and management of tardive syndromes, and be able to institute treatment or refer patients when treatment is appropriate. Future research may focus on the potential benefit of earlier introduction of VMAT2 inhibitors to delay onset or progression of tardive syndromes. More effective treatments are still needed, as are effective, well-tolerated antipsychotics that do not cause tardive syndromes.