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Guidance From Dr. Rakesh Jain on Treating TD During the Pandemic

June 04, 2020

logoIn this video, Psych Congress Steering Committee member Rakesh Jain, MD, MPH, offers guidance on the proper treatment of tardive dyskinesia (TD) during the COVID-19 pandemic.

"Let's make sure the cause of these patients is not forgotten by us," said Dr. Jain, Clinical Professor, Department of Psychiatry, Texas Tech University School of Medicine, Austin. "Let's understand while ideal examinations of our patients with TD may not be possible, telepsychiatry doesn't shut the door towards actually pretty good care."

Read the transcript:

Hello, everybody. This is Rakesh Jain, a psychiatrist and a proud member of the Psych Congress Steering Committee. I sincerely hope, during these difficult times with the pandemic occurring, that you, your family, and your patients are doing well.

I'm looking forward to this opportunity to have a deep conversation with you about the many challenges our patients with tardive dyskinesia face today. Despite these challenges, there might be opportunities for us to serve them well. This particular conversation, hopefully, will drive home a few points that could help all of us serve our patients better. Let's have that conversation.

The first thing we should remember is that tardive dyskinesia has been with us for a very long time, in fact for decades, in fact pretty much the entire time we have had antipsychotics since the 1950s. It's also appropriate to remember that for several decades, we did put tardive dyskinesia on the back burner. We didn't think about it too much.

That situation did change in the last three 3 years or so, when we obtained some very effective FDA‑approved treatments. My big worry is — and you perhaps share this with me — that this pandemic that we're facing may push tardive back to its original place of being ignored, of being forgotten. I say that's not appropriate.

Yes indeed, it's become much more difficult to assess our patients. Telepsychiatry is a difficult media through which to do that. It has become more difficult to perhaps truly understand their biopsychosocial difficulties as a result of tardive dyskinesia.

I think we may have to bring our A‑game to the table now, do our very best to do even a partial examination, do our very best to understand the psychosocial impact that tardive dyskinesia may be having on them, and do our best to address it. We cannot go back to how things were decades ago. Tardive dyskinesia does deserve our attention.

Another point of conversation we should have is the issue of the rules and regulations not having changed just because we are going through a pandemic. We have been asked by the guidelines, by the American Psychiatric Association, to consider evaluating all patients before we start them on an antipsychotic for an abnormal movement disorder.

You know what? That has not changed just because the COVID pandemic is here. We're also recommended by the APA to conduct such assessments at regular intervals depending on the patient's age, as well as the kind of medication they were on, typical or atypical. That has not changed. That has not been suspended.

Somehow or another, we will have to find a way to continue practicing high‑quality mental health psychiatry even in these very complex times. Part of that obligation does require us to assess periodically for abnormal involuntary movements, almost certainly using a scale such as the AIMS.

No conversation about tardive dyskinesia can be complete without us touching upon the AIMS scale. The AIMS is pretty much the gold standard in the field, is it not? It's been with us for some decades. It's been a wonderful instrument.

This COVID pandemic does make it very difficult to use it ideally, in the way it was designed, because you do have to touch the patient as part of the examination. We certainly can't do that over telepsychiatry, but there are many elements of the AIMS that can be done.

For example, the activation maneuvers can be done. We can ask the patient to bring over the camera closer to certain body regions that we wish and need to examine. We can also ask the patient directly, and their support system, if they have noticed any difficulty with walking, talking, or any other aspect of the motoric functioning.

While it is very true this pandemic has challenged us and our patients to no end, it's not necessary that we suspend our use of the AIMS just because of our current complexities. We can still do it.

Here's another issue I wanted to discuss with you, which is the issue of adherence. Adherence has always been a challenge in psychiatry and particularly so in patients with tardive dyskinesia. That's an old problem.

These COVID‑19 pandemic times have really exaggerated those difficulties. It's rather important we talk about it to see if there might be ways we can reduce the challenges our patients have with adherence of their medications that help them with tardive dyskinesia.

Some of the things that we could do is perhaps pull in the support system even closer than we have before. If a patient is living with a family member, with the patient's permission, we might want to pull them into the conversation about remembering to take their medication.

If they're living in a situation such as a group home, we might want to, again with the patient's permission, perhaps pull in the staff members to have a conversation about how to improve adherence.

We could perhaps, with a more functional patient who still is having challenges with adherence, ask them to use the calendar, or if they even have a smartphone, perhaps put alerts on it. We will have to remind our patients that optimum adherence with their medications for the treatment of tardive dyskinesia may be critically necessary for optimum outcome.

We should also talk about nonpharmacological means to help our patients with tardive dyskinesia. Certainly, medication treatment, perhaps with an FDA‑approved medication for the management of tardive dyskinesia, is crucially important. In fact, it's central to their care.

Nonpharmacological techniques such as stress management, reduction of alcohol consumption, or even stopping excess alcohol consumption, not eating foods that might lead to obesity, sleep hygiene, all of these are important in the management of both short‑term as well as long‑term tardive dyskinesia difficulties our patients have.

Let's not forget the importance of these tools because the care of a full patient does require us, the clinicians, to think along the lines of both pharmacologic and nonpharmacologic treatments that are combined for the patient's betterment.

Thank you so much for spending some time with me talking about a disease state that for decades was not given the respect it deserved. Patients with tardive dyskinesia did not quite get the attention they deserved, but things have changed so much now. We now have effective treatments.

Now this COVID pandemic might really push their cause back unless we, the mental health professionals, say, "That's unacceptable. Not under my watch."

As a result, I suggest the following. Let's make sure the cause of these patients is not forgotten by us. Let's understand while ideal examinations of our patients with TD may not be possible, telepsychiatry doesn't shut the door towards actually pretty good care. We just have to bring our A‑game to this issue. Don't you think so?

One more time. Thank you so much for spending time with me talking about this important topic. I wish you and your patients the very best. Goodbye for now.

MORE: Treating TD in the COVID-19 Era: 5 Steps to Success
 

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