Prescriptions of antipsychotics have increased over time, driven by the use of atypical antipsychotics for mood disorders, including major depressive disorder (MDD). While these drugs are essential for many patients with MDD, they can also cause tardive dyskinesia (TD), a persistent, often irreversible, hyperkinetic movement disorder, which can have a profound impact on patients’ ability to perform daily activities, be productive, and socialize.
Patients with mood disorders are often highly functioning and can be severely impacted by even subtle movements. While all patients taking antipsychotic drugs are at risk of developing TD, mood disorder has been recognized as an additional risk factor. Consequently, clinicians should closely monitor subtle movement changes and assess their impact to ensure patients receive appropriate treatment.
In this case study, Carol was prescribed an atypical antipsychotic following a severe depressive episode and subsequently developed TD. After experiencing episodes of mouth twitches and repetitive blinking, Carol became concerned about how the movements would impact the way she was perceived at work. After she sought a second opinion, her clinician diagnosed TD and noted its impact on her life, subsequently offering treatment with a vesicular monoamine transporter 2 (VMAT2) inhibitor.
This case underscores the importance of assessing the impact of TD, regardless of the severity of movements, especially in patients with mood disorders like Carol.
Not an actual patient.
Carol, a 36-year-old woman, undergoing treatment with an antidepressant and an atypical antipsychotic for the management of MDD
Carol is recently engaged and being considered for partnership in a major accounting firm. She was diagnosed with MDD at the age of 29 and was treated with an antidepressant. Following a severe depressive episode, she began adjunctive treatment with an atypical antipsychotic and has since remained stable for several years.
Recently, she has noticed abnormal movements, including mouth twitches and repetitive eye blinking, which were noticed by a colleague who then made a joke about illicit drug use. She told her psychiatric clinician she had been feeling anxious about both wedding planning and her partnership interviews. The clinician acknowledged her comments and movements; however, the clinician noted that the movements were mild and did not ask further questions or see a need for additional investigation.
No clinical studies have been conducted to evaluate the effects of treating TD on the outcomes discussed here.
Carol told her coworkers that she had dry eyes to explain the excessive blinking, but the movements in her mouth and hands would worsen during stressful meetings and near important deadlines. She was concerned about her movements worsening during her upcoming partnership interviews, which could impact her chances of being promoted. Her awareness of these movements was affecting her daily life and contributing to her anxiety. As a result, she sought a second opinion to have her concerns about the movements addressed.
During the clinical examination, her new clinician observed excessive blinking and slight puckering of the lips as she waited to begin the session and inquired if Carol was aware of the movements. Carol acknowledged them and expressed worry about the worsening of movements in her hands and mouth under stress, and their potential impact on her career. She also mentioned experiencing jaw pain, which indicated additional orofacial involvement. The clinician conducted an activation maneuver and observed mild “piano playing” in her fingers. Based on these observations, the clinician diagnosed TD and, recognizing its impact on the patient, prepared for a discussion about treatment.
The American Psychiatric Association (APA) recommends treatment of TD that has an impact on the patient, regardless of the severity of movements. Based on the impact of movements on Carol’s life, she and her clinician discussed appropriate treatment. To manage Carol’s TD, her clinician started treatment with a VMAT2 inhibitor, the only FDA-approved treatment for TD, without making any adjustments to her current regimen of antidepressant and adjunctive antipsychotic therapy.
Carol’s movements improved with treatment ahead of her partnership interviews and wedding. As a result of the reduction in movements, Carol felt more at ease in social situations, such as her wedding. Throughout ongoing conversations with her clinician, Carol understood that TD typically persists, potentially requiring lifelong treatment. To that end, she plans to continue treatment while regularly seeing her new psychiatric provider to manage her MDD.
Antipsychotic medications prescribed for mood disorders such as MDD can lead to the development of TD, which is characterized by abnormal, involuntary movements
Small, subtle movements associated with TD can negatively impact daily activities, and may worsen the mood of patients with MDD
It is critical that providers ask questions to uncover the impact of subtle movements on their patients’ lives
APA guidelines recommend VMAT2 inhibitors—the only FDA-approved treatment for TD—if TD has an impact on the patient, regardless of the severity of movements
Carol’s case study highlights the need for clinicians to carefully assess movements and their impact in patients with mood disorders who are taking antipsychotics, and appropriately treat TD that has an impact on the patient
American Psychiatric Association. The American Psychiatric Association Practice Guideline for the Treatment of Patients With Schizophrenia. 3rd ed. Washington, DC: American Psychiatric Association; 2021. Accessed January 27, 2025. https://psychiatryonline.org/doi/pdf/10.1176/appi.books.9780890424841
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.
Data on file. Teva Neuroscience, Inc. Parsippany, NJ.
Dhieb D, Bastaki K. Pharmaco-multiomics: a new frontier in precision psychiatry. Int J Mol Sci. 2025; 26(3):1082.
Hauser RA, Meyer JM, Factor SA, et al. Differentiating tardive dyskinesia: a video-based review of antipsychotic-induced movement disorders in clinical practice. CNS Spectr. 2022;27(2):208-217.
Jackson R, Brams MN, Citrome L, et al. Assessment of the impact of tardive dyskinesia in clinical practice: consensus panel recommendations. Neuropsychiatr Dis Treat. 2021;17:1589-1597.
Jain R, Ayyagari R, Goldschmidt D, et al. Impact of tardive dyskinesia on physical, psychological, social, and professional domains of patient lives: a survey of patients in the United States. J Clin Psychiatry. 2023;84(3):22m14694.
Jain R, Konings M, Thompson S, Yang A, Kotak S, Gandhi P. Real-world evidence of patient experience with once-daily deutetrabenazine extended-release tablets for tardive dyskinesia and chorea in Huntington disease in the United States. Presented at: Annual Psych Congress; October 29-November 2, 2024; Boston, MA.
Mathews M, Gratz S, Adetunji B, et al. Antipsychotic-induced movement disorders: evaluation and treatment.Psychiatry (Edgmont). 2005;2(3):36-41.
McCutcheon RA, Keefe RSE, McGuire PK. Cognitive impairment in schizophrenia: aetiology, pathophysiology, and treatment. Mol Psychiatry. 2023;28(5):1902-1918.
Ward KM, Citrome L. Antipsychotic-related movement disorders: drug-induced parkinsonism vs. tardive dyskinesia-key differences in pathophysiology and clinical management. Neurol Ther. 2018;7(2):233-248.
