Tardive Dyskinesia a 'Silent Driver' of Healthcare Spending

 Tardive dyskinesia (TD), a movement disorder characterized by involuntary tics and twitches, exacts a substantial financial toll on patients and the healthcare system.

TD "is a silent driver of healthcare costs and disability," said Jose Rubio, MD, PhD, of the Institute of Behavioral Science at Northwell Health in Manhasset, New York.

The disorder can develop after exposure to any antidopaminergic agent and occurs at a rate of approximately 4% to 8% per year in adult patients treated with first-generation antipsychotic agents, according to American Psychiatric Association (APA) guidelines.

While the risk of TD is lower with newer, second-generation agents, the threat still remains. "TD is not something from the 1980s," Rubio told MedPage Today. "It is still prevalent even with second-generation antipsychotics, stigmatized, and perhaps more under-recognized than in the 1980s."

Drivers of Healthcare Use

Several factors drive high healthcare use among people living with TD, particularly medication adjustments, according to Meghan Musselman, MD, of Temple University Hospital in Philadelphia.

"The diagnosis of tardive dyskinesia often warrants medication dose adjustments, medication changes, or addition of medications to treat tardive dyskinesia. Changing a medication or adjusting a medication dose may result in an exacerbation of mental health symptoms, requiring additional psychiatric care," Musselman told MedPage Today.

Reducing an antipsychotic dose to quell TD movements can heighten the risk of psychosis relapse. "Once the dose of relapse-prevention antipsychotic treatment goes below a certain threshold, psychosis relapse is much more likely," Rubio noted. "I would advise being careful about decreasing the antipsychotic dose, which could transiently worsen TD and increase the risk of relapse."

Even when doses are steady, data suggest that developing TD independently may increase the risk of breakthrough psychosis, he added.

High comorbidity rates further compound healthcare needs. A 2019 case-control study of psychiatric inpatients found that people with TD were significantly more likely to have cardiometabolic conditions -- including obesity, hypertension, and diabetes -- and faced a 1.5-fold higher risk of comorbid substance abuse.

Additionally, TD patients experienced more severe functional impairment and were less likely to be discharged home, resulting in higher admission rates to skilled nursing facilities.

A 2019 retrospective claims analysis also highlighted a surge in healthcare utilization. In the study, patients used significantly more healthcare resources in the 12 months after a TD diagnosis than in the 12 months prior. Post-diagnosis, inpatient admissions jumped (55.5% vs 26.1%) with longer average stays, and emergency room visits increased (61.5% vs 50.6%).

High Cost of Healthcare

This spike in healthcare utilization can inflate subsequent costs. The claims analysis revealed a 26% increase in total all-cause healthcare costs following a TD diagnosis, rising from $43,312 to $54,656 annually, primarily driven by inpatient admissions, outpatient services, and pharmacy expenses.

Similarly, the case-control study found that patients with TD accrued $20,415 more in average costs than psychiatric inpatients without TD, alongside a 6.36-day longer average hospital stay. Emergency department visits and inpatient hospitalizations represent the most expensive services in psychiatry, Rubio pointed out.

International data reflected similar trends. A 2024 German claims analysis showed that patients with TD had higher rates of all-cause hospitalizations (62.1% vs 48.7%), emergency visits (35.9% vs 25.1%), and outpatient neurology visits (69.7% vs 40.5%) compared with matched controls. Annual post-index mean costs were also nearly double for the TD cohort.

"In psychosis, most of the cost is indirect," Rubio emphasized, adding that TD-related disability translates directly to lost wages for both patients and caregivers. "A recent study showed that out of the $366.8 billion annual cost of schizophrenia in the U.S., $291.8 billion were indirect costs -- including lost and unpaid wages, and impact on caregiver health."

The physical symptoms of TD also disrupt everyday life, Musselman observed. "Symptoms may attract unwanted social attention, causing embarrassment, social isolation, missed work, and impaired psychosocial functioning. This functional decline is a critical driver of longer and more frequent hospitalizations," she said.

Prevention and Early Intervention

When antipsychotics are clinically necessary, routine screening is essential to catch symptoms early, Musselman advised.

"Clinicians providing antipsychotics should conduct an assessment of TD at the outset of treatment and at least annually, and more frequently in individuals at high risk," she said. "Because TD is often irreversible, early detection is critical to prevent progression if possible."

When TD occurs, Rubio emphasized the importance of discussing the diagnosis openly with the patient. "TD is very stigmatized, and just understanding the impact of TD in the patient's life can be quite relieving," he noted.

First-line treatment should involve an approved VMAT2 inhibitor, Rubio advised. Off-label strategies -- like switching to antipsychotics with low TD risk, such as clozapine or xanomeline/trospium (Cobenfy) -- can be considered if VMAT2 inhibitors fail, he added. "Providing adequate care is the best solution to decreasing long-term costs," he said.

Disclosures

Rubio reported relationships with Teva, Bristol-Myers Squibb, Alkermes, Neurocrine, and UpToDate.

Musselman reported no disclosures.

https://www.medpagetoday.com/spotlight/tardive-dyskinesia/122461