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Tardive dyskinesia - Diagnosis and assessment

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Current guidelines and approaches to Tardive Dyskinesia management

The use of antipsychotic medications has expanded greatly over time. As their use becomes more widespread, it is increasingly important to monitor patients for the potential development of Tardive Dyskinesia (TD).1 The goals of TD management are to maintain stability of the underlying psychiatric condition, ensure a positive risk-benefit balance when introducing management strategies, and to reduce the severity of TD so that it does not substantially impact patients’ quality of life.2–4 Read the article below to learn more about the current guidelines and approaches to TD management.

TD is most commonly linked to the long-term use of dopamine receptor blocking agents (DRBA), particularly antipsychotics.5 While TD can develop after as little as three months (or one month in patients older than 60 years) of exposure, it more commonly emerges after one to two years of continuous therapy.5 Notably, symptoms persist in the majority of patients even after discontinuation of the DRBA, highlighting the importance of early detection and appropriate management to improve patient outcomes.5
United States (US) guidelines, such as those from the American Psychiatric Association (APA), provide detailed information on how and when to assess individuals who are at risk of TD.6 However, European guidelines for TD screening and assessment, such as those from the National Institute for Health and Care Excellence (NICE), British Association of Psychopharmacology (BAP), and the German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN), are typically less specific than those published in the US.7–9

European guidelines for screening and assessment note the following:

The NICE guidelines recommend that when antipsychotics are initiated, baseline measurements should be taken in secondary care. Regular monitoring may subsequently be done in primary care on specialist advice or depending on the person’s care plan. This may include monitoring for the emergence of movement disorders7

The BAP guidelines suggest that “extrapyramidal side effects (EPS) remain important non-target actions of antipsychotic medication. Clinicians should maintain a high level of awareness and monitor for EPS regularly, preferably using a standardised recording instrument”8

DGPPN suggests that “older people (>65 years old) who receive long-term antipsychotic treatment are specifically evaluated for the presence of TD. Besides an exact diagnostic classification of the dyskinesia, the functional effects and extent of the impairments in quality of life should be assessed”9

While adjusting (i.e. decreasing or increasing) the antipsychotic regimen has been suggested as a strategy for managing TD, current evidence does not adequately support the safety or effectiveness of this approach.10 Reducing the dose or discontinuing antipsychotic treatment entirely may lead to a deterioration in the patient’s psychiatric condition.10 Conversely, increasing the dose may temporarily mask TD symptoms, but this can result in the worsening of the condition over time.10 However, switching to an atypical antipsychotic with lower dopamine D2 receptor affinity may be effective in reducing TD symptoms.10

In Europe, access to pharmacological treatments for TD is limited. Furthermore, the absence of universal and specific guidelines for TD management contributes to inconsistencies in care.7–9 To improve patient outcomes, there is a need for better access to effective therapies, the development of standardised management protocols, and the implementation of coordinated, multidisciplinary care.11,12

References

  1. Kane JM, Correll CU, Citrome LL. Epidemiology, prevention, and assessment of tardive dyskinesia and advances in treatment. J Clin Psychiatry. 2017;78:1136–47.

  2. Caroff SN, Citrome L, Meyer J. A modified Delphi consensus study of the screening, diagnosis, and treatment of tardive dyskinesia. J Clin Psychiatry. 2020;81:19cs12983.

  3. Jackson R, Brams MN, Citrome L. Assessment of the impact of tardive dyskinesia in clinical practice: Consensus panel recommendations. Neuropsychiatr Dis Treat. 2021;17:1589–97.

  4. Bhidayasiri R, Boonyawairoj S. Spectrum of tardive syndromes: Clinical recognition and management. Postgrad Med J. 2011;87:132–41.

  5. Waln O, Jankovic J. An update on tardive dyskinesia: From phenomenology to treatment. Tremor Other Hyperkinet Mov (NY). 2013;3:tre-03-161-4138-1.

  6. APA. The American Psychiatric Association Practice Guideline for the Treatment of Patients With Schizophrenia. Third edition. Washington, DC: APA, 2021. Available at: https://psychiatryonline.org/doi/book/10.1176/appi.books.9780890424841 (accessed July 2025).

  7. NICE guidelines. Psychosis and schizophrenia in adults: Prevention and management. Updated March 2014: available at: https://www.nice.org.uk/guidance/cg178/chapter/Recommendations (accessed July 2025).

  8. Barnes TRE, Drake R, Paton C, et al. Evidence-based guidelines for the pharmacological treatment of schizophrenia: Updated recommendations from the British Association for Psychopharmacology. J Psychopharmacol. 2020;34:3–78.

  9. German Association for Psychiatry, Psychotherapy and Psychosomatics, DGPPN. Updated March 2019: available at: https://www.dgppn.de/_Resources/Persistent/b794e84f9cbdf0d761b26cb1bd323b65188cb9e6/038-009e_S3_Schizophrenie_2019-03.pdf (accessed July 2025).

  10. Ricciardi L, Pringsheim T, Barnes TRE, et al. Treatment recommendations for tardive dyskinesia. Can J Psychiatry. 2019;64:388–99.

  11. Cloud LJ, Zutshi D, Factor SA, et al. Tardive dyskinesia: Therapeutic options for an increasingly common disorder. Neurotherapeutics. 2014;11:166–76.

  12. Bhidayasiri R, Phokaewvarangkul O, Shang H-F, et al. Tardive dyskinesia in Asia— current clinical practice and the role of neurologists in the care pathway. Front Neurol. 2024;15:1356761.

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