Telepsychiatry: Monitoring TD Movements and Medication Management

In Part 2 of this interview, Richard Jackson, MD, founder and owner of The Neurobehavioral Medicine Group, Associate Clinical Professor, Wayne State University School of Medicine, Detroit, Michigan, and the Oakland University Beaumont Hospital Medical School in Royal Oak, Michigan, and Assistant Clinical Adjunct Professor, University of Michigan School of Medicine, Department of Psychiatry in Ann Arbor, Michigan, discusses monitoring movements and speaks more about medication usage during a telepsychiatry TD visit.

In Part 1, Dr Jackson discussed assessment through the use of AIMS for tardive dyskinesia (TD) via telepsychiatry.

Dr Jackson:

Back to 1982, in a landmark case, Clites v Iowa, a court established that the requirements for clinicians are to appropriately use antipsychotic medications what a reasonable physician would do, as well as appropriate monitoring, which does include monitoring and potential treatment, which we now have available for tardive dyskinesia (TD).

When we look at movements that may be apparent to us, and there may be some hidden movements that we can talk to patients about, but in addition to that is really discussing with patients the impact of their movements.

We do that from looking at impact with regard to impairments in functioning. Do they have difficulties putting away glasses? Do they have functioning difficulties with regard to their daily activities, maybe writing, maybe walking, maybe even talking, breathing?

Asking about how it impairs their day-to-day functioning. Beyond the physical impairments that you may see from abnormal movements, what is the potential emotional difficulties? Do they feel depressed related to their movements? Do they feel that they're isolated? Do they want to avoid others? Do they feel embarrassed? These are typical type feelings that patients with TD may experience but not be able to verbalize.

Patients with schizophrenia often minimize or deny having movements or how it may interfere with their functioning. Do we look at patients and see some spills on their clothes? Or not tying their shoes? Even patients that may be shaving cutting their face and asking is that related to movements, or may it be part of the core psychiatric illness?

Then other symptoms such as physical pain. Are they biting the insides of their mouth, or clenching their teeth to suppress movements, or that they may not even be aware of? We know that we look for movements through face, upper extremities, lower extremities, and truncal areas, shoulders, hips, and neck. That can cause a variety of physical impairment such as pain. Chronic dystonias, where you have continued contractions of muscles, may cause cervical pain as well as impairments and difficulties in functioning.

The only thing that may be difficult on a telepsychiatry or visit where you are not seeing the patient directly, is differentiating sometimes between TD and drug-induced parkinsonism. We know that we can see a tremor fairly well, and maybe even slowness, so we want to ask patients to do things that may bring out tremor or slowness. Some of those same rapid alternating movements on 1 side may bring out tremor in the other.

Stiffness may be a bit difficult. We might have to ask patients about stiffness or ask them to move their extremities and see if you can pick up stiffness, which is generally felt versus visualized.

We might speak to patients that, "Although we're seeing you by telepsychiatry or some type of video visit, we can capture many of the movements, but we may be limited in some areas." Explaining that to patients and helping them to understand that also speaks to the standard of care as to how there may be some limitations with regard to visits during a telepsychiatry visit.

In general, what we want to do is provide information with regard to the medication that we may be using. We document and talk to patients of the appropriate use, what we're treating, why we're treating with this type of disorder, what the potential risks are, including TD. That's all part of standard informed consent.

Alternatives that may be available, as well as risk of not treating, monitoring for part of the abnormal movements regularly, baseline AIMS exam, periodic AIMS, but always looking for abnormal movements when we see patients.

Following abnormal movements and offering, when appropriate, the available treatments for abnormal movements, which are now FDA approved and available to us because we are looking to not only decrease movements but play a role with regard to patients' day-to-day functioning and speak to patients about their impairments in their functioning.

Hopefully, these tips will be helpful for you. Good luck during these difficult times. Thank you.