This animated video visually explores the distinct mechanisms of action (MOAs) of anticholinergics and VMAT-2 inhibitors in managing tardive dyskinesia. It highlights the efficacy and safety differences between the two drug classes, emphasizing how VMAT-2 inhibitors target dopamine dysregulation at the synaptic level, resulting in more targeted and effective symptom relief compared to the broader and less specific effects of anticholinergics.
This video series offers guidance on performing the Abnormal Involuntary Movement Scale (AIMS) exam, a standardized tool for assessing tardive dyskinesia and other movement disorders. The videos include visual representations of the severity levels for each assessment, helping healthcare providers accurately evaluate and document involuntary movements.
This video showcases comparisons of patients with tardive dyskinesia (TD) before and after treatment, highlighting the visible improvements in involuntary movements. Through real-life examples, it demonstrates how treatment can significantly enhance patients' quality of life.
In this instructional video, Psych Congress co-chair Rakesh Jain, MD, MPH, explains the importance of the Abnormal Involuntary Movement Scale (AIMS) exam in the diagnosis and monitoring of patients with tardive dyskinesia. Dr. Jain reviews the components of the AIMS and runs through the steps for conducting the exam, illustrated with clips of a patient (portrayed by an actor) to show the various activation techniques.
This video is part of a larger presentation featured at the Psych Congress Regional Meetings, as well as the 30th annual national Psych Congress meeting in New Orleans, Louisiana in September 2017. The activity was supported by an educational grant from Teva Pharmaceuticals.
As an April 2023 article published in The Journal of Clinical Psychiatry concluded, “Tardive dyskinesia imposes a substantial burden on patients’ physical, psychological, social, and professional lives and impacts management of their underlying condition.”
Psych Congress Network sat down with Kevin Williams, MS, MPAS, PA-C, Psych Congress steering committee member, at the 2024 NP Institute to discuss the often-overlooked social and professional dimensions of life with tardive dyskinesia (TD). In Part 1 of this series, Nurse Williams highlights key findings from the 2023 TD patient survey, discusses comorbidity challenges, and addresses challenges that patients with TD may face in the workplace and beyond.
For more clinical insights on TD care, visit our Tardive Dyskinesia Excellence Forum.
Read the Transcript:
Kevin Williams, MS, MPAS, PA-C: My name is Kevin Williams, and I am the lead clinician and CEO for On Point Behavior Health in Tampa, Florida.
Psych Congress Network: Recently, the Journal of Clinical Psychiatry published findings from a survey assessing patient burden of tardive dyskinesia. What are some of the most impactful insights from this study?
Nurse Williams: So the study showed that 3 out of 4 patients with tardive dyskinesia reported feeling self-conscious, and even some feeling embarrassed. But it also showed that patients had worsening social withdrawal and mental/physical dysfunction along with their quality of life being reduced. When we see how the impact goes well beyond just a physical condition, we really begin to understand that we should be provoked as clinicians to really make a change in our assessment and screening for this.
Listen, one of the salient points from the study showed that 33% of caregivers observed severe impact to their loved ones. It's a large number of observation from caregivers on those patients. So, if not only the caregivers are noticing them, what we as clinicians should be doing is really assessing our patients and screening them appropriately to ensure that we're jumping in as early as possible to treat TD.
Psych Congress Network: Patients with underlying schizophrenia reported the highest burden of TD across all domains. What implications does this have for clinicians treating patients with schizophrenia and comorbid TD?
Nurse Williams: So often as clinicians, we're focused on treating the condition. I know talking with several of my colleagues even when dealing with patients who have schizophrenia, we get so focused on treating the positive and negative symptoms that we commonly see with schizophrenia. Well, through the study we're really able to see that we now have another layer that really has to be unpacked: our understanding of it as clinicians and then our approach with how we're treating patients who also have TD.
My recommendations in doing this is really starting early with the conversations with our patients who have schizophrenia and when possible bringing in caregivers so that we're really using a team approach to begin to discuss. We now have appropriate treatment to be able to effectively treat our patients, so they no longer need to be socially withdrawn or facing any of the physical or psychological dysfunctions that we commonly have been seeing with the studies that we've conducted.
My approach to really the implications in treating schizophrenia with comorbid TD is that it's just another layer that we have to begin to discuss and accounting for in our treatment plans when it comes to treating both schizophrenia and tardive dyskinesia.
Psych Congress Network: What impacts does TD have on work productivity and activity impairment among TD patients? How should clinicians adjust treatment approaches with these in mind?
Nurse Williams: We come to understand through the research performed by Dr Jain et al. that the impact of TD goes well beyond just the physical, social, and psychological factors that we were assessing. I find that our community really needs to take these facts and begin to assess the impairments that our patients could possibly be experiencing in their work environment and in other environments as well, and then taking these facts and really beginning to utilize the tools that we have. We have the impact TD scale, or really just simply taking that and asking the questions, really infusing it into our visits so that we obtain the information, are quickly able to score those items and draw out how our patients are being impacted.
Another approach that I really think that we should take in adjusting our treatment options is just asking the patients. I've learned that simply asking them, have they noticed these changes or their caregivers about these changes, that it opens up a dialogue that we get so used to our routine visits and what we are going to assess, that just adding that question into it really can begin to open up proper dialogue that we will then gain new insight and then be able to appropriately address through treatment plans.
Thank you so much for tuning in today and learning how this study really can impact us as clinicians, along with the impact that TD has on our patients.Listen, please return back at any time and come back and check out and see what we have available to you in regards to content and more information for not only TD but other conditions as well. Thanks so much.
Kevin N. Williams MS, MPAS, PA-C is the CEO and Lead Clinician at OnPoint Behavioral Health. He is a Physician Associate that specializes in Psychiatry as well as 2 master degrees in Interdisciplinary Medical Sciences and Physician Assistant Studies from the University of South Florida and South University respectively. He has gained experience treating children, adolescents, and adults for the past 9 years in the areas of inpatient, outpatient, and long-term care.
Gain fresh insights into the multifaceted impacts of tardive dyskinesia (TD) with Psych Congress Steering Committee Member Desiree Matthews, PMHNP-BC, as she explores the physical, social, and emotional consequences faced by patients living with TD. Matthews describes key assessment strategies and the differences between VMAT2 inhibitors, offering valuable insights for health care professionals in managing this condition.
For more TD treatment insights and resources, visit our Tardive Dyskinesia Excellence Forum.
Read the Transcript:
Desiree Matthews, PMHNP-BC: Hello, my name is Desiree Matthews. I am a psychiatric nurse practitioner, and I work at a community mental health center in Charlotte, North Carolina.
Question: What are the non-physical consequences individuals with TD may face, and why is it crucial health care professionals understand these impacts?
Nurse Matthews: When it comes to patients living with tardive dyskinesia, we unfortunately know this can have a physical impact on patients. For example, falls risk and changes in their strength and mobility.
But, sometimes what we don't talk about is the impact on social and emotional wellbeing. We know through various surveys and studies that patients certainly do recognize these movements. They can feel embarrassed and withdraw from social activities.
If you ask care partners or caregivers, they too share a burden with patients living with tardive dyskinesia, including having to help patients make appointments and feeling worried about a patient not being able to do something at home. Also, they're coming home early from work because they need to help console a patient or help make appointments—communication needs.
Really, tardive dyskinesia is very pervasive in terms of its impact on all domains. Again, we have a lot of studies and new growing evidence for that.
Q: What are the key assessment strategies for TD detection and evaluation, and how can they benefit health care professionals?
Nurse Matthews: When it comes to screening for tardive dyskinesia, it is really important for us as providers to understand the recommendations for our screening tools. Number one, the American Psychiatric Association (APA) recommends that we do an abnormal involuntary movement scale every 6 to 12 months for patients at high risk and then at least once a year for patients at usual risk.
It's also important to note that [the APA] wants to step further beyond the AIMS scale and make sure that we clinicians do a clinical assessment for TD and other movement disorders at every single encounter or visit.
So, what does that mean? What does a clinical assessment look like?
For me and other clinicians in practice, a clinical assessment includes looking for TD by briefly using a few activation maneuvers to see if we can uncover any movements, for example, watching them when they're walking down the hall to our appointment. Also asking key targeted questions.
We have a few tools out there now, one being the Impact TD scale, to help us ask questions in very patient-centric language—asking them about movements, asking if there's impact to their daily activities. We also have the MIND-TD questionnaire that we can use as a brief screener. The great thing about that is anybody that trained in the office can use this very helpful tool.
Q: Can you briefly highlight the differences between the VMAT2 inhibitors approved for the treatment of TD?
Nurse Matthews: For our options here in the US, we have 2 VMAT2 inhibitors approved for the treatment of tardive dyskinesia in adults—deutetrabenazine and valbenazine. There are no head-to-head studies when it comes to efficacy or safety, but what I can tell you is that the differences lie in the pharmacodynamics and the pharmacokinetics.
I think the most important thing to understand is that these 2 molecules are different. They both block VMAT2 and the important thing is we understand that they are both FDA approved.
They are both efficacious and very well tolerated in most individuals. Because they are different, I do recommend to patients and their families that if they do not do well on one VMAT2 inhibitor, we can try the other. When you're conforming a treatment plan, you have to understand pathways in terms of metabolism and drug-drug interactions.
I approach VMAT2 inhibitors and look at the patient as a whole on their needs and their current medical medications because this may have me go to one VMAT2 inhibitor over the other.
Thank you all for joining me today, my name is Desiree Matthews and check back for more updates.
Desiree Matthews, PMHNP-BC, is a board certified psychiatric nurse practitioner with expertise in treating patients living with severe mental illness. Beyond clinical practice, Desiree has provided leadership in advocating for optimal outcomes of patients and elevating health care provider education. Desiree is the founder and owner of Different MHP, a telepsychiatry practice founded with the mission of providing affordable, accessible precision focused, integrative psychiatry to patients through a rich and comprehensive mentorship of the health care providers within the company.
Read the transcript:
Hi, I'm Dr Craig Chepke. I'm the medical director of Excel Psychiatric Associates in Huntersville, North Carolina, an adjunct associate professor of psychiatry for atrium health, and a steering committee member and a scientific director for Psych Congress.
When assessing for TD, it's critical to make sure that we are doing a differential diagnosis to make sure that we are actually diagnosing and treating tardive dyskinesia.
There has been an increase in the awareness and the ability and desire for clinicians to assess for TD in the past several years, and that delights me, but we don't want to jump to thinking that everything that moves is tardive dyskinesia, because that would be the pendulum swinging too far in the other direction. For too many decades, all we talked about was extra pyramidal symptoms (EPS) which is just a garbage basket diagnosis of pretty much any abnormal and voluntary movement. That's one thing that led down the pathway of us using anticholinergics like benztropine for everything that is an antipsychotic-related movement disorder.
The primary differential that most clinicians have to grapple with is tardive dyskinesia versus drug-induced Parkinsonism. Akathisia and dystonia, I think, most clinicians are able to tease out. Akathisia has that inner sense of restlessness, they can't stop moving, and they feel uncomfortable because of it. Dystonia is a sustained muscle contraction rather than intermittent movements in most cases.
So, it's TD versus Parkinsonism.
The way to differentiate one is the time frame. If you notice the symptoms come on right after an antipsychotic is started or increased in dosage or if you switch from a lower potency to a higher potency, that's one clue that it could be drug-induced Parkinsonism because that's an acute motor adverse reaction. Whereas tardive dyskinesia—tardive means just like the word “tardy,” if your kids are late for school, they're tardy.—tardive dyskinesia has late onset, months to years after starting the antipsychotic or other dopamine blocking medication.
In terms of the phenomenology of the movements themselves, you can differentiate. Movements of TD are a chorea form or athatoid, so dance -like, worm -like, snake -like, they're usually slower, although they can be fast in some cases, but usually slower, and they're not rhythmic.
In drug-induced Parkinsonism, generally, Parkinsonism is a slowness of movement—bradykinesia, akinesia,—but they can have some kind of islands, I call them, of hyperkinetic movements. Movements usually in the hands (the pill-rolling tremor), in the lips (a rabbit tremor where the lower lip kind of vibrates sometimes), you can get a titubation which is kind of like a bobblehead that the head bobbles about. But, what you have to remember is: number one, it's a tremor, and any tremor is perfectly rhythmic whereas the movements of TD are not rhythmic. They may have a pattern, but you can't exactly predict what they're going to be based on what they did in the past 5, 10, or 30 seconds like you can with a tremor because a tremor repeats itself more or less infinitely.
Then also, look at the whole person.
We'd always need to think about the whole person in many aspects but one is in this differential as well because as I mentioned Parkinsonism is usually slowness of movements and reduced movements. So even if we do see a hyperkinetic movement in their hands and in their lips, what's going on in between the two? Does the rest of their body not move very much when they walk? Do they have no arm swing and take small slow steps? Does the rest of their face, other than their lips, have no movement whatsoever and it looks like they've been over-botoxed? They don't have any wrinkles on their face? They don't blink. Things of that nature.
Don't get into a staring contest with someone with Parkinsonism, you'll never win because they can't blink. Whereas with TD, they have either normal movements or excess movements throughout the body as opposed to the juxtaposition of some parts of having too many movements and some parts having too few.
So, those would be 3 of the ways that I would make that differential, and it's critical because making the right diagnosis is going to dictate your treatment, and treatment for one, could worsen the other. The VMAT-2 inhibitors, the approved and recommended treatments for TD, can cause drug-induced Parkinsonism in some people. And anticholinergics like benztropine, which can be used and are approved for drug-induced Parkinsonism, have the potential to worsen TD.
But also remember one more time, benztropine and other anticholinergics are not the only treatments for drug-induced Parkinsonism. Amantadine is also approved and very useful and does not have many of the adverse reactions that benztropine has. It does have adverse reactions we have to watch for, but it's my medication of choice if I'm treating drug-induced Parkinsonism.
Read the Transcript
Psych Congress Network: What strategies can clinicians use to prevent patients from altering their medication or discontinuing visits due to TD symptoms?
Nurse Williams: First, for me, discussing treatment options with VMAT2 inhibitors is a tool with motivational interviewing that I try to utilize much early on in treatment. If the patient begins to have movements, we've already discussed this, so we can revisit that conversation, but I've already advised them that this could happen, and if it does happen, that treatment was there. It begins to build trust between me and my patient and the family in regards to how we're going to treat and what we can do; knowing that I was able to give foresight to those things.
Another approach that I use is what I call the individualized approach. If a patient is sharing that they are stopping medication—whether that be an anti-psychotic or the treatment that I have them on with a VMAT2—we pause and begin to really ask the question as to why. Not in a general sense, "Well, clearly I don't want to take the medicine," I get that. But, why are you [the patient] not wanting to do this? Then, what can we do to begin to utilize the education that we have to begin to motivate the patient that this behavior is not necessarily the best option, and then moving through a treatment plan of getting them back on the medication, ensuring that they're adhering to taking it consistently, and getting them better.
Psych Congress Network: How can clinicians help TD patients manage social challenges highlighted in the recent Journal of Clinical Psychiatry while maintaining overall well-being?
Nurse Williams: So, we saw in the study that 3 out of 4 patients began to express self-consciousness or embarrassment regarding their symptoms of TD, and that caused a social withdrawal and then also a worsening of quality of life. I believe that as we begin to manage the challenges that our patients have, we must remember that we're not treating two separate conditions. The patients are having one experience in lif, so understanding and communicating that TD can produce challenges which also begins to affect their social implications and how they perceive things and how others perceive them, along with some of their mental health disorders which could be doing this very same thing, is so key so that the patient understands that all of this encompassing really affects their way of life. If we are able to communicate that effectively, then patients will be more agreeable to starting medication to treat their TD along with their mental health disorders.
Psych Congress Network: What actionable recommendations can clinicians take from this study to improve the treatment and support of TD patients? How can caregivers be a part of this conversation?
Nurse Williams: So, I feel there are 3 actionable items that we as clinicians can take.
First, screen your patients. Whether that’s with the AIMS or the IMPACT-TD, a scale that we have, we must screen our patients and feel convicted to do that screening. I have worked with training my team, my clinical team, my front office team, anyone that I work with to understand what TD is, that we could see it in the office, and that we are all responsible for ensuring that we as clinicians are aware of it and how to treat it.
Talking about treatment, I believe when we're starting and initiating the antipsychotic that we know that there's potential prevalence of having TD, so starting that conversation early in treatment. Before 2017 we didn't have treatment, so now that we have appropriate treatment, we should ensure that we're moving and shaping the way our patients are treated is so important for us to be able to do that. So that's action item number 2.
Lastly, when it’s appropriate and when we can, include caregivers in our treatment. Utilizing shared decision-making allows for the patient, the caregiver, and you as the clinician, to really be able to utilize a powerful tool in treatment. Then they become our allies—they are the eyes and ears while we're not with the patient and being able to help us to understand what's taking place at home and in social environments.
Utilizing these 3 tools really helps us to not only identify TD but treat TD for the duration of the condition.
Thank you so much for tuning in today and learning how this study really can impact us as clinicians, along with the impact that TD has on our patients.
Listen, please return back at any time, check out what we have available to you in regards to content and more information for not only TD but other conditions as well. Thanks so much.
Kevin N. Williams MS, MPAS, PA-C is the CEO and Lead Clinician at OnPoint Behavioral Health. He is a Physician Associate that specializes in Psychiatry as well as 2 master degrees in Interdisciplinary Medical Sciences and Physician Assistant Studies from the University of South Florida and South University respectively. He has gained experience treating children, adolescents, and adults for the past 9 years in the areas of inpatient, outpatient, and long-term care.