Carol S. North, MD, MPE, DLFAPA
Adjunct Professor in Psychiatry
(volunteer), The University of
Texas Southwestern Medical
Center, Dallas, TX, USA
The Elusive Diagnosis of Tardive Dyskinesia in Psychiatric Practice
Tardive dyskinesia, or TD, is an involuntary movement disorder that can occur after treatment with antipsychotic medication. This condition can be hard to reverse and may cause embarrassment, stigma, social isolation, reduced quality of life, and problems with daily functioning. A published review of 41 studies of TD with 11,493 patients taking antipsychotic medications found that 25% developed TD.1 TD differed across studies and groups of patients but was highest among state psychiatric hospital inpatients.
To examine TD in a real-world setting, we did a study at a large community mental health treatment center, Metrocare Services, in Dallas, Texas.2 At the time, this facility provided outpatient care each year for serious mental illness and developmental disabilities to 62,000 adults and children. We reviewed medical records of more than 120,000 Metrocare outpatients treated from 2013 to 2017. Nearly one-fourth of the patients had a psychotic disorder, and one-fourth were children under 18. About 80% of both adults and children with psychotic disorders were prescribed antipsychotic medication.
A widely used tool to assess abnormal involuntary movements, including those associated with antipsychotic medication use, is the Abnormal Involuntary Movement Scale (AIMS).3 This scale was built into Metrocare’s medical record system, reminding providers to check for abnormal movements at least once a year. However, only about half (51%) of the patients receiving antipsychotic medication had AIMS information entered in their medical records. In the records that were completed for patients prescribed antipsychotic medication, only 1% of adults and almost no children were found to have TD, typically affecting the face, extremities, and trunk. Only one-third (32%) of the patients with a positive AIMS test had TD diagnosed by the provider. In summary, the public sector workers in our study did not always complete and record AIMS testing, and they rarely identified TD.
Our study used information recorded by busy providers as part of their normal outpatient care in a real-world setting. Another study also using medical record data found TD in only 1%-2% of patients.4 The rates found in these clinical studies are substantially lower than the general 25% rates1 reported by research studies dedicated to systematic recording of symptoms. The findings from these clinical studies suggest that clinicians may not be assessing for TD or are missing it when they do. This may be because they do not have enough time or staff to do regular formal movement checks.3,5
These findings matter for the many patients in public sector psychiatry and general psychiatric care settings with psychotic disorders who are prescribed antipsychotic medications. Because medications to treat TD are now readily available, it is more important than ever to identify and treat TD. This may be accomplished by training clinicians to systematically assess for TD, using better medical software to track abnormal movements, and giving clinicians enough time and staff for identification and treatment of TD.
参考
- Carbon M, Hsieh CH, Kane JM, Correll CU. Tardive dyskinesia prevalence in the period of second-generation antipsychotic use: a meta-analysis. Journal of Clinical Psychiatry, 2017; 78:e264-e278.
- North CS, McDonald K, Hunter J, Burruss J. Prevalence of tardive dyskinesia in an electronic medical record study at a large community mental health treatment center. The Primary Care Companion for CNS Disorders, 2022; 24(4):41627.
- Kane JM, Correll CU, Nierenberg AA, Caroff SN, Sajatovic M. Revisiting the abnormal involuntary movement scale. Journal of Clinical Psychiatry, 2018;79(3):17cs11959.
- Loughlin AM, Lin N, Abler V, Carroll B. Tardive dyskinesia among patients using antipsychotic medications in customary clinical care in the United States. PloS One, 2019; 4;14(6):e0216044.
- Caroff SN, Yeomans K, Lenderking WR, Cutler AJ, Tanner CM, Shalhoub H, Pagé V, Chen J, Franey E, Yonan C. RE-KINECT: a prospective study of the presence and healthcare burden of tardive dyskinesia in clinical practice settings. Journal of Clinical Psychopharmacology, 2020; 40(3):259-68.
