APPs often serve as frontline clinicians treating patients in a variety of settings, including clinics they own and operate, as well as those managed by counselors and psychiatrists. Their work spans community mental health centers and private practices as well as inpatient and outpatient facilities. APPs are already heavily involved in assessing, diagnosing, and treating patients with TD across various healthcare settings. Given the ongoing shortage of psychiatrists, I believe their roles will evolve, and we might see them conducting more research and even serving as primary investigators on clinical trials. They will also play a crucial role in educating other NPs and physician assistants, particularly new graduates or those transitioning into psychiatry. Additionally, they may be taking on executive and leadership roles, overseeing large healthcare organizations, and managing other healthcare providers.
In the United States, TD is often undiagnosed and untreated, with approximately 15% of patients with TD receiving a formal diagnosis and less than 6% of patients being treated with vesicular monoamine transporter 2 (VMAT2) inhibitors, the only FDA-approved treatment for TD.
What I'd like my colleagues to understand is that even mild movements can have a significant impact on patients' lives. Moreover, the impact of TD may extend beyond the patient; individuals close to someone, such as spouses, parents, children, or friends, are often affected and they may also become more isolated. It is thus critical to recognize TD and treat it appropriately.
In my experience, a key reason for the high rate of TD underdiagnosis is that clinicians may not be aware of the guidelines provided by professional organizations such as the American Psychiatric Association (APA). Awareness of the guidelines is one thing, but implementing them into clinical practice is another challenge altogether. To enhance TD diagnosis, I think we should integrate these guidelines into our patient evaluation charts.
Expert consensus recommends that patients taking antipsychotics should be screened for movements at every visit regardless of the risk for TD. In addition, the APA recommends assessment with a structured instrument such as the Abnormal Involuntary Movement Scale (AIMS) at a minimum of every 6 months in patients at high risk of TD and at least every 12 months in other patients, as well as if a new onset or exacerbation of preexisting movements is detected at any visit. High-risk patients include individuals older than 55 years; women, including post-menopausal females; individuals with a mood disorder, substance use disorder, intellectual disability, or central nervous system injury; individuals with high cumulative exposure to antipsychotic medications, particularly high-potency dopamine D2 receptor antagonists; and patients who have experienced other movement disorders such as acute dystonic reactions or clinically significant parkinsonism. TD develops after using an antipsychotic for at least a few months, although elderly persons may develop TD symptoms in a shorter period of medication usage. Personally, I conduct standardized screenings every 3 months for high-risk patients and every 6 months for everyone else.
My approach centers on understanding patients’ personal goals and their desired way of living and recognizing that many face challenges and have developed coping strategies for managing TD. When assessing impact with patients, I ask direct questions such as "Are you avoiding the store?" or "Do you find socializing difficult?" I also inquire if their family, friends, or coworkers have commented on increased feelings of embarrassment during social or family gatherings. Sometimes, individuals experience challenges with certain activities, particularly if they involve hand movements. Therefore, I might ask if they have difficulties with tasks like buttoning a shirt, using zippers, holding silverware, or engaging in activities requiring fine hand movements. They might not notice that they spill things more often or need extra time to get dressed. It is critical to realize that patients who have been managing their symptoms for a long time may not fully realize how much these issues affect their daily lives until they experience improvement. Therefore, it’s important to treat the symptoms and then ask patients to reflect on how the reduction in movements has impacted their ability to perform day-to-day activities that were previously difficult.
I continue to utilize telepsychiatry services, although my practice is primarily office-based and in-person, with most of my providers and myself working from the office. It is possible to effectively assess movements during telehealth visits by following a few best practices. First, it's essential to ensure the patient is in a well-lit area. If possible, have someone assist with holding or positioning the camera to capture a full body view of the patient. This setup can be beneficial, especially if you need to zoom in on a specific area for closer examination. To reduce reflections and improve the assessment of facial movements, I request that patients remove their glasses and provide an unobstructed view of their face. Additionally, providing enough floor space for the patient to walk from point A to point B can allow you to observe their gait by zooming out. Most importantly, whether in telehealth or in the office, remember to focus on your patients rather than just on the computer or notes.
First and foremost, I would urge them to 'STOP!' prescribing anticholinergics for TD, given that the prescribing information for benztropine warns that antiparkinsonism agents do not alleviate the symptoms of TD and may, in fact, worsen them. While anticholinergics may be suitable for other conditions, such as acute dystonia or drug-induced parkinsonism (DIP), they may exacerbate TD symptoms. In my experience, doing nothing would be better than prescribing anticholinergics for TD. However, rather than taking no action, I recommend using the FDA-approved VMAT2 inhibitors, which can effectively reduce movements in patients with TD. So, it is critical to accurately diagnose TD and treat it appropriately.
First, AUSTEDO has a demonstrated efficacy and safety profile, established in 2 randomized, placebo-controlled clinical trials. The most common adverse reactions reported in patients with TD treated with AUSTEDO (>3% and greater than placebo) were nasopharyngitis and insomnia. Second, increasing improvement in AIMS total score was observed through 3 years in an open-label extension (OLE) study, with 71% of patients at Week 145 seeing improvement relative to Week 15. Finally, patient-reported ease of use with AUSTEDO XR was highlighted in a real-world survey, in which 98% of patients said taking once-daily AUSTEDO XR was easy, and 95% planned to continue taking AUSTEDO XR.
When speaking with patients, I make it a priority to explain the diagnosis and its underlying causes. At times, I use YouTube videos or other resources on my computer to show them what the condition looks like and why it occurs. I educate my patients on the chronic nature of TD and the need to stay on treatment. Then, I discuss treatment options. If I am going to offer a patient AUSTEDO XR, I will note what was observed in the clinical trials and explain what they can expect with treatment. I will then talk about how we will titrate the dose of their medication until we find a dose that is tolerable and achieves desired symptom control.
Usually, I start my patients on the 4-week Titration Kit. In the real-world START study, patients and physicians reported treatment success with the 4-week Titration Kit that was consistent with pivotal studies, as well as overall satisfaction with the Titration Kit and ease of following the titration schedule. Additionally, over 90% of patients adhered to the Titration Kit, with the majority reaching a dosage >24 mg/day by Week 4.
One of my patients with a long history of mood disorders was diagnosed with TD. She was unemployed and somewhat isolated, with limited family contact. Initially, she was on AUSTEDO BID but later transitioned to AUSTEDO XR. TD prevented her from being able to paint as a hobby, because the movements interfered with her ability to hold a brush. Treatment with AUSTEDO XR significantly reduced her movements, and as a result, she was able to hold a paintbrush and paint with less difficulty, providing her with a renewed sense of purpose. My patient’s experience is not an isolated case. In fact, results from a real-world survey showed that more than 50% of patients reported improved social and emotional well-being as a result of movement reduction with AUSTEDO XR. I was grateful that by treating my patient's TD movements, I could help her do something again that brought her joy. We, as healthcare professionals, can and should be champions for our patients.
