Telephone Visits Not Recommended Telehealth Treatment Medium For TD Evaluation

In this video, Rif El-Mallakh, MD, University of Louisville School of Medicine, Kentucky, discusses his study that found that experts feel telephone visits are not adequate for the evaluation of tardive dyskinesia (TD), and while still challenging, video interviews should be utilized instead to see the patient’s physical health.

Researchers presented the study in a poster at the recent Schizophrenia International Research Society (SIRS) 2021 meeting.

In the previous Part 1 of this video, Dr. El-Mallakh discusses the methods of his study that sought to learn more about how clinicians diagnose, assess, and manage TD in both in-person and telehealth settings and how TD impacts both patients and their caregivers.

Read the transcript:

The panel viewed VMAT2 inhibitors as being durably efficacious and well-tolerated. By durably efficacious, meaning that their effectiveness was maintained over time. We all agreed that VMAT2 inhibitors are and should be used as the first-line treatment in both psychiatry and neurology for tardive dyskinesia.

When we started talking about the assessment of tardive dyskinesia in our patients, we felt that it was important to assess the effect of those movements on the patient's level of function and their quality of life. We felt that these particular cues were the things that patients and their caregivers found to be particularly important.

We felt that conversations with patients and caregivers about quality of life and about functionality allowed or helped patients overcome some of the barriers to treatment. One of the barriers this would specifically address is the sense that, “oh my God, yet another medication that you want me to take”.

We thought that coming from the direction of something that patients and their caregivers care about was a way of recruiting the patient and their caregivers in the treatment decisions.

There was also unanimity among the panel with frustration of current medical terminology. Specifically, there was universal disdain for the term extra-parametal symptoms or EPS. We felt this term generally confounds disparate conditions like Parkinsonism, which is a hypokinetic condition, and tardive dyskinesia, which is a hyperkinetic condition.

When you confuse these with one term that encompasses both of them, really creates confusion, perpetuates misunderstandings, leads to such poor practices as the use of anticholinergics to treat tardive dyskinesia.

The experts on this panel agreed that addressing the issue of terminology, along with more clinician education and understanding the key differences among drug-induced movement disorders can improve both the diagnosis and the treatment of tardive dyskinesia in our patients.

In terms of telehealth or telepsychiatry, all the experts agreed that telephone visits are just not adequate or not sufficient for evaluation of TD. Telephone visits may not live beyond COVID, but virtual video visits are more likely to.

Virtual video visits are the minimum, because it's necessary to be able to see the patient's abnormal movements and see how these movements actually change over time with any treatment we might begin.

We still felt that telepsychiatry was challenging, because there are issues with lighting and technology. A lot of our patients don't have access to good Internet connections, and so you get this really horrible chopped up image, which itself makes its own abnormal movements, if you will. Issues like camera position. All of these are problems, some of which have solutions and some of which don't.

In general, and this the general way that, for example, at the University of Louisville, we approached this, that there is a pre-visit that's done with one of our front office staff, where the patients are educated about how to use the system, how to position it, a little bit about the lighting.

That can also be done in real time, where the clinician, for example, would have the patient move the camera, or at least move in ways that you can see parts of the body. I always think that modeling the movements for the patients is an essential way of getting the patients to understand and to feel comfortable with doing things like opening their mouth to the camera and that sort of stuff.

We also felt that you can go ahead and use family members to help with maybe the camera if that type of caregiver is available. The problem was that you still couldn't really see the body. Ultimately, you need to do things like look at the toes or look at the fingers. When I'm doing an abnormal involuntary movement scale (AIMS) exam, my eyes are rushing back and forth between the mouth and hands.

In general, the panel felt that in-person visits are still necessary. We feel that at least once yearly is a reasonable schedule for in-patient visits if your patient really wants to do virtual visits.

Overall, we were pleased that clinicians in general seem to be aware that there are approved medications for tardive dyskinesia. We continue to be concerned about the ongoing need for better screening. Making the correct diagnosis, appropriate measurements of the movements so that you can follow them over time, and then making sure that the clinicians begin appropriate treatments.

We feel that emphasis on the burden of what these movements do to the patients is important, because that allies you with how patients and caregivers see their illness. Specifically, we wanted to focus on severity. We understand that studies have to focus on severity to actually show that the drug works.

However, the panel felt that even mild cases of TD would end up affecting patients, their level of frustration, embarrassment, negative feelings towards themselves. We felt that it's important to address TD from the patient's point of view, rather from this medical standard of it has to be this level of severity.

We hope our study and that results of our study help other healthcare professionals to learn more about tardive dyskinesia. We hope that sharing this information will improve conversation between caregivers and patients and their family members, and maybe even inspire other thought leaders in the field to increase the level of education of clinicians in managing tardive dyskinesia and diagnosing it.

Thank you very much for listening to this presentation. Have a good day.

Dr. Rif El-Mallakh is currently a professor at the Department of Psychiatry of the University of Louisville School of Medicine.  He has been there since 1992.  He joined the faculty after completing a research fellowship at the National Institute of Mental Health to establish the Mood Disorders Research Program.  Over the past 30 years Dr. Rif El-Mallakh has focused on the ionic pathophysiology of bipolar illness, the deleterious consequences of antidepressants, and the tardive syndromes.  He has published over 300 peer-reviewed papers and chapters, 2 books, and has received over 5 million dollars in funding over his career from NIMH, Brain and Behavior Research Foundation (BBRF or NARSAD), other research foundations, and the pharmaceutical industry.