Traditionally, it was thought that the severity of TD movements determined the overall impact on the patient. However, in the last decade, it has become clear that the severity of movements is only part of the picture. In fact, TD can have a broader impact on patients’ lives, leading to significant impairment in critical areas. These include physical challenges related to speech, swallowing, or breathing; social implications, including the substantial stigma attached to abnormal movements; and psychological impact, such as hopelessness or anger. In my experience, patients with TD may feel a sense of betrayal toward both their clinician and the medication that caused this condition. They might feel let down by their own minds and bodies, which may no longer be able to perform simple tasks, and they may encounter stigmatization from others as a result of their abnormal movements. This creates the perfect storm that leads to the functional impairment that many patients face. As a result, American Psychiatric Association (APA) Guidelines state that TD that impacts patients should be treated, regardless of severity of movements.
In the early stages of my career, I only encountered TD in individuals with schizophrenia. Now, it’s becoming more prevalent in individuals with mood disorders who rely on medications that can cause TD. In fact, the use of atypical antipsychotics to treat mood disorders is thought to be the primary cause of the increasing rates of TD in the United States. These individuals may experience a more severe impact from TD because they are often highly functioning and therefore more aware of even small movements. Additionally, some may discontinue their medication due to feelings of betrayal and the mistaken belief that it will halt the progression of TD. This has the potential to destabilize their underlying mental health disorder. Therefore, it’s essential for clinicians to raise awareness among our patients and colleagues about the high potential for TD in this population, engage in more careful screening by looking and asking about movements, and treating patients if TD impacts their lives.
Individuals close to someone with TD, such as spouses, parents, children, or friends, are often affected. Caregivers can experience the burden of TD in various ways. They may need to help the patient with daily activities, such as meal preparation and driving, and they may experience psychological distress, such as anxiety or worry. Caregivers may also face social repercussions due to the patient’s TD, such as strained friendships, or they may withdraw from social activities. I like to use the term “meta-metastatic disease” to accurately capture the far-reaching and profound effects of TD on both the individual and their social network.
Until recently, the assumption in psychiatry was that TD was primarily found in community mental health centers, state hospitals, and in individuals with schizophrenia. It wasn’t until a decade ago that we realized that TD is present in every practice. Additionally, there was a misconception that atypical antipsychotics had resolved the issue of TD, when in fact they are now recognized as drivers of new cases. The reluctance to address TD primarily stems from discomfort in assessing and differentiating TD from other movement disorders. Furthermore, I believe that clinicians may lack familiarity with the use of vesicular monoamine transporter 2 (VMAT2) inhibitors and may hold misconceptions regarding their use, whether it is necessary to discontinue antipsychotics, and potential side effects.
Ultimately, we can encourage our colleagues to adopt the “see something, do something” principle—recognizing TD movements and the potential impact on patients and initiating the appropriate therapy.
This study is truly unique and the first of its kind worldwide, contributing significantly to our understanding of TD. The data demonstrate the consistency of impairment levels among patients with TD, irrespective of the severity of movements, and this distinct characteristic makes TD stand out among other movement disorders. Additionally, the study establishes the chronic nature of TD, providing long-term insights into our patients’ experiences. This highlights the continuous and pervasive nature of the disorder and emphasizes the need for ongoing treatment. Thus, this study is likely to be regarded as a landmark study in our understanding of TD.
Psychiatry clinicians tend to start low and go slow. C%linicians may be treating TD with the lowest dose that improved some movements for the patient, assuming that this minimal level is the therapeutic target. I would like to encourage them to consider impairment as their benchmark, and if the patient continues to experience impairment in some aspect of their life, the clinician should consider continuing to increase the dose. An important feature of AUSTEDO XR is that it provides a range of therapeutic doses and offers flexibility to achieve effective and tolerable control. In pharmacokinetic studies, increased plasma levels correlated with higher potential for treatment success, as measured by Clinical Global Impression of Change and Patient Global Impression of Change scales, but not higher potential for adverse events.
Most participants reported that their abnormal movements improved compared with how they felt before treatment with AUSTEDO XR. They also noted that this reduction had a positive impact on their lives and daily activities. In addition, they appreciated the flexibility of taking AUSTEDO XR with or without food and at different times of the day. However, there was also some indication of suboptimal dosing, underscoring the potential for additional improvement in some patients.
Overall, this real-world study demonstrated that, as movements improve, there is a genuine potential for enhancement in the individual’s life beyond merely suppressing the movement. This progress is not only inspiring for the prescribing clinician but also for the entire clinical team, as it reflects improvements in movement severity, social interaction, and physical functioning.
