Your Questions Answered: Optimizing Tardive Dyskinesia Care

In this podcast from the June 2023 Psych Congress Regionals virtual meeting, clinical professionals Amber Hoberg, MSN, APRN, PMHNP-BC, and Jonathan Meyer, MD, answer audience questions on their session, "More than Skin Deep: Examining the Full Impact of Tardive Dyskinesia." Saundra Jain, MA, PsyD, LPC, moderates.

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Read the Transcript:

Saundra Jain: Welcome back, everyone. Amber, Jonathan, it's so nice to see both of you this evening. Glad that you're here with us. I want you to know we don't have a long time for Q&A, maybe right at 10 minutes, but we've got more than enough questions. So let's get started.

Amber, let me toss this one to you: In patients where no medication works on improving [tardive dyskinesia (TD)], are there some exercises or anything that might make the situation more tolerable and improve quality of life? Not including the concerns about suicide and depression.

Amber Hoberg: So I would say that, really, there's not any kind of exercises or anything that can be done to improve it. This is an irreversible, permanent condition, and it's going to impact these patients and cause problems in their life, if it not addressed with medications. Even the American Psychiatric Association says that the first-line treatment for TD is VMAT 2 inhibitors and that they should be used to treat patients, especially if they have mild moderate or severe disabling TD. But with mild cases, if it's impactful the patient’s life, really, the only way you can treat this and make it better for the patient is actually to use the on-label treatments.

Saundra: Good to know. Jonathan, this is an interesting question--I'll ask you this one. Of the medicines that you guys talked about, any chance that they will become generic anytime in the near future?

Jonathan Meyer: I don't remember the exact patent expiration dates, but they're fairly long patent lives. So, the 2 which are approved for target dyskinesia, which are valbenazine and deutetrabenazine will be proprietary for the foreseeable future.

Saundra: Got it.

Okay, lots of interest and questions about the AIMS exam. Amber, I know that both you and Jonathan, because of COVID, we're doing a lot of our work virtually. This group of clinicians wants to know what can be done to optimize the AIMS assessment in telehealth format. They add a comment that it’s obviously not ideal, but sometimes it's the only way. Amber, would you kick that off?

Amber: Absolutely. I still see 80% of my patients virtually. So, I do the AIMS on a daily basis virtually. And yes, while it's not ideal—of course, ideal is always in person—please don't ever not do the AIMS just because you're doing virtual care. I always say a modified AIMS is better than no AIMS at all. You can do an AIMS exam pretty well when you can see all 4 areas of the face. So, I can get the first 4 questions.

If I ask my patient hold their arms out in front of them, I can observe the upper extremities, a lot of the trunk, the neck, and the shoulders. Only thing I may not be able to see is the lower extremities, but I can ask my patients questions about their lower extremities. Or if they have a helper in their house, I can ask them, “Hey, do you mind if your mom helps you with the camera” so that they can hold it down, and I can see your legs to see what's going on. But I can always ask patient questions as well if they don't have a helper.

So, I do the AIMS with success. The biggest thing is to make sure that you activate patients when you do the AIMS so that you can really see what those movements look like when they're the worst for the patient. Activation even through virtual is still very important to do. I make the diagnosis of TD and treat via virtual care all the time.

Saundra: Got it. Jonathan, how about for you in terms of virtual assessments?

Jonathan: I think Amber alluded to it—you can do most of it, but document what you do. If you can't see lower extremities, just document it and say, “I wasn't able to see them.” If the patient has other complaints where they need to be in the office, I haven't found a way, Amber, to assess for rigidity via Zoom. For some things, you just may have to bring them into the office once in a while. But once you've established that they don't have TD symptoms in their lower extremities, then, as Amber said, you could just ask them from time to time if they’ve noticed anything.

Saundra: Got it. Jonathan, I have had this question about TD persisting for years after a person stops their antipsychotic medications. Is that something that we would expect to see?

Jonathan: Yes. Sadly, I think Amber also said it, TD tends to be irreversible. The degree of reversibility in the literature is around 12 to 13%. There are some people if you catch it very early, if you stop the drug right away, you might reverse it. For most people, though, it remains an irreversible condition. That's been the sad part—it doesn't go away in most people, even after you stop the offending agent.

Saundra: Gotcha. Amber, how about this one? Clinicians want to know, can the sudden decrease in antipsychotics induce TD?

Amber: Yes, they absolutely can. I have seen this in my older population. I take care of a lot of geriatric populations. One of the things that we do in long term care is called gradual dose reductions, which means that the patient doesn't need to be on the antipsychotic medication or they don't need to be at that dose. We have to lower the dosing down. I do find that sometimes it will unmask TD. First generation antipsychotic drugs are actually more risky. They tend to cause that problem more where it masks it at a higher dose, but when you start to go under the threshold, and you start to see TD come out of the woodwork. So, I have seen this to be problematic for patients that as we decrease the dose, I have seen TD become a problem for patients where maybe it wasn't. I mean, a lot of times we know that if we raise the dose of the antipsychotic, those movements sometimes will dissipate, but that's not the treatment for TD. Because eventually what will happen is those movements will become more problematic and, rear its ugly head again, even after you increase the dose.

Jonathan: Can I echo just what Amber said? The process was already there. It's not like lowering the dose caused the TD—you just didn't see that it was there. It was latent, as we say. So you're actually doing the right thing by lowering a dose in many circumstances, but now it unmasks the process that was already there. Then you see it worsens the symptom but the process was already there to begin with.

Saundra:  Gotcha. Jonathan, we have only about 45 seconds left, but I'd like to toss this question to you because it ranked pretty high in interest. This group of clinicians is asking, if a patient fails one of the VMAT 2 inhibitors, is it worthwhile or recommended to try the other one?

Jonathan: Short answer, yes. Some people fail for a number of reasons, and you might as well give the other a crack. The 2 best drugs we have, which are valbenazine and deutetrabenazine, just to see if you can get benefit from one versus the other. If you don't get benefit from maximum doses of either, then those are the people who get referred on to a movement disorder specialist.

Saundra: Got it. Beautifully stated. Well, I've said this a number of times today, but it seems worth saying again that when moderating, I always learn something. I so enjoy it.

The only thing I don't like is being the timekeeper, and so I'm still going to have to do with that. We are at time this evening. I wish we had double the time because the questions really are very large in number. But let me thank both of you for joining us this evening. It really is such an interesting Q&A and TD is often an under-addressed topic. So, I know that I along with our attendees are very grateful to both of you for raising it to all of our attention is to continue to have the conversation about TD. So thank you both.

Amber Hoberg, MSN, APRN, PMHNP-BC, is a board-certified psychiatric mental health nurse practitioner from the University of Texas Health Science Center, San Antonio. She has been working for the past 12 years with the adult and geriatric populations treating all types of psychiatric conditions. Her background, as a psychiatric advanced practice nurse, includes outpatient, inpatient, group home, and nursing home/ALF settings. She currently works for Med Management Associates and Morning Star Family Medicine PLLC treating the chronically mentally ill in both inpatient and outpatient settings.

Jonathan Meyer, MD, is a voluntary clinical professor of psychiatry at University of California, San Diego, and a distinguished life fellow of the American Psychiatric Association. Dr Meyer is a graduate of Stanford University and Harvard Medical School, finished his adult psychiatry residency at LA County-USC Medical Center and completed fellowships there in Consultation/Liaison Psychiatry and Psychopharmacology Research. Dr Meyer has teaching duties at UC San Diego and the Balboa Naval Medical Center in San Diego, and is a consultant to the first episode psychosis program at Balboa NMC.

Saundra Jain, MA, PsyD, LPC, is an adjunct clinical affiliate, school of nursing, at The University of Texas at Austin. In 1992, she launched a private practice of psychotherapy where she currently provides services for a wide range of mental health issues. Dr Jain is a co-founder of the WILD 5 Wellness Program and a member of the Psych Congress Steering Committee. Dr Jain obtained her master's degree from the University of Houston-Clear Lake and a doctoral degree from Southern California University for Professional Studies; she is a Licensed Professional Counselor. She has an MBA from Texas Woman's University. She was selected for a Postgraduate Clinical Fellowship at the University of Texas Medical Branch, Galveston, Texas where she trained in the Division of Child and Adolescent Psychiatry.