Measurement-based Diagnosis and Treatment for Tardive Dyskinesia

Tardive dyskinesia (TD) is an involuntary movement disorder associated with agents that block dopamine receptors, particularly antipsychotics. TD commonly involves the orofacial muscles and extremities, and, because these movements are out of the patient's control, they can have serious physical and psychological effects. An accurate and early diagnosis of TD is crucial because the risk of permanence increases over time. To minimize the risk of TD development, clinicians should use the lowest necessary doses of dopamine receptor blocking agents, and, if allowed by the treated condition, the dopamine receptor blocking agents should be stopped after the shortest necessary time. Clinicians should try to avoid parkinsonian adverse effects and akathisia and prefer second-generation antipsychotics over first-generation antipsychotics. Moreover, clinicians should differentiate between TD and other drug-induced movement disorders, particularly drug-induced parkinsonism, as anticholinergic treatment can worsen TD. To facilitate measurement-based care, clinicians should use the Abnormal Involuntary Movement Scale examination to screen for and routinely monitor TD, especially when providing treatments intended to decrease the symptoms and impact of TD. Two vesicular monoamine transporter-2 (VMAT2) inhibitors, deutetrabenazine and valbenazine, are approved by the US Food and Drug Administration to treat TD. For patients who have moderate to severe or disabling TD, the American Psychiatric Association recommends treatment with the VMAT2 inhibitors. Clinicians should communicate with patients and care partners about risk factors for and signs of TD, as well as available treatment options for TD and what they can expect in terms of short- and long-term results.