eCase: Impact of TD on Patients With Mood Disorders

• CME
• CE

Key Research

In the past, people thought of TD as something that happens only to people with very severe, chronic illness who are on high doses of strong antipsychotic medications. In recent years, however, there has been an increase in evidence of therapeutic effect of SGAs in a number of psychiatric conditions, including affective disorders.

Low-dose SGA augmentation of a mood stabilizer has led to higher remission rates and more rapid remission in both manic and depressive exacerbations of bipolar disorder.¹

In maintenance treatment of bipolar disorder, augmentation with a low-dose SGA delays or prevents relapse vs treatment with a mood stabilizer alone.² Similarly, augmentation with a low-dose SGA significantly increases the likelihood of remission vs treatment with antidepressants alone in patients with recurrent MDD who have had an inadequate therapeutic response to antidepressants.^3,4

According to some treatment algorithms for depression and bipolar disorder, low-dose SGAs are now a second step after initial antidepressant treatment for MDD or lithium treatment for bipolar disorder.^2,5

Patients with bipolar disorder or recurrent MDD are more likely to achieve sustained remission than are patients with schizophrenia.⁶ Because patients with mild bipolar disorder or MDD tend to have more insight and better cognition than those with schizophrenia or psychotic bipolar disorder, they are more likely to be socially active and participate more fully in personal relationships, school, or work.^6,7 Similarly, they are more likely to be aware of abnormal movements, even movements that are rated “mild” on the AIMS exam, and are more likely to feel the social and emotional impact of their dyskinetic movements.⁸

In the majority of cases, TD is irreversible. This severity and permanence make it the most important extrapyramidal adverse event of antipsychotics. The movements commonly involve the face and may include excessive blinking, grimacing, chewing, lip-smacking, and tongue-protruding movements that are disfiguring and socially embarrassing. Even mild movements may interfere with social and occupational functioning. The increased use of dopamine receptor antagonist and partial agonist agents in patients with affective disorders has increased the population at risk for developing TD and the total incidence of TD. Although first-generation antipsychotics show higher risk for and severity of TD, it does still occur in patients treated with SGAs.² One of the most consistently found risk factors for the development of TD is being 55 years of age or older^9,10; another is the past or current presence of current extrapyramidal symptoms including akathisia, parkinsonism, or dystonic reactions.¹¹ There has also been some evidence that females may be more susceptible to developing TD than males.¹⁰

There are currently 2 FDA-approved treatments for TD.^12-14  Deutetrabenazine and valbenazine, which are VMAT2 inhibitors, have both demonstrated continued efficacy for a year.^15-17 Both also have had impressive safety profiles, with very low rates of treatment discontinuation during the preapproval trials and postmarketing surveillance. Upon discontinuation, abnormal movements can return, making long-term treatment with a VMAT2 inhibitor necessary. TD is debilitating, has an impact on social and emotional functioning, and increases overall disease burden. Treatment with an FDA-approved VMAT2 inhibitor can have a positive impact on quality of life of those who develop TD.

References

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