Strategies for Managing Tardive Dyskinesia, With Alejandro Alva, MD

At the Southern California Psychiatry (So Cal Psych) Conference in Huntington, CA, from July 11 – 12, Alejandro Alva, MD, chief medical officer and CEO for Pacific Neuropsychiatric Specialists, presented 2 sessions: “Evaluating Patients with TD” and “Treatment-Resistant and Difficult-to-Treat Depression: Definitions and Illness Burden.” During an on-site interview, Alva shared how to identify tardive dyskinesia, the importance of “pushing the dose” to get maximum benefit, and exciting medications in the pipeline for treatment-resistant depression.

HCPLive: Can you tell us a little bit about your session on tardive dyskinesia?

Alva: We're going to be talking about how to identify tardive dyskinesia. As you know, targeted kinetic movements have become an interesting topic in psychiatry. The reason why I say that is because prior to recent times, we did not have any type of treatment for that type of movement disorder…We kind of hung our hat on the risk-benefit analysis, saying, Well, you need this medication so that you don't have psychosis, and you want to have quality of life, but then this kinetic problem could also cause social isolation. It could cause disfiguration.

It was not until recently, with the advent of the BM2 inhibitors, that we became not only more adept at treating it but effective at treating it.

The first order of business is to realize that a) with the use of any dopaminergic blocking medication, we run the risk of [tardive] dyskinesia. Number two, we need to be able to identify these patients, because historically, we haven't been able to, or we haven't really looked for it, which is even worse, right?

What we do now is use different tools, for example, the aim scale and plain look at your patient. Okay, stick your tongue out at me. Open your mouth. Let me look at your toes…Do I see any truncal movements that shouldn't be there? Those types of things.

HCPLive: How do you approach choosing between the 2 available medications for tardive dyskinesia?

Alva: It is a personal preference, really, and it also hinges on insurance constraints.

Sometimes, we have to kind of go with the formulary. When we look at efficacy rates, they're very similar, especially with the extended-release formulations… Sometimes you try a medication, and the patient doesn't do as well as we would expect, and that's when you switch…So do I have a particular preference? Not really. I will go with whatever I can get my hands on quicker so that the patient can actually benefit quicker.

The other thing that is important is to push the dose to what I consider to be the maximum efficacious dose. A lot of clinicians tend to underdose… The challenge that I would throw out there for any clinician is [to] push the dose, see what happens, because I can guarantee you that you will be surprised.

HCPLive: Is it fair to say that giving a therapeutic dose a full trial is essential before switching?

Alva: Absolutely. I say, look, at least four weeks. At the very least, add a therapeutic dose. And if you get to that point and it's not working, then, yeah, it's fair game [to] switch. Don't just say…there’s nothing else I can do, because we do have options.

HCPLive: You’re also covering treatment-resistant depression. How do you define and differentiate it from difficult-to-treat depression?

Alva: That's an interesting topic because there is a differentiation between treatment-resistant depression and difficult-to-treat depression.

We now know that they are treated similarly, but there are differences. What we want to put out to the general public and to our colleagues is the fact that there are multiple treatment modalities that can be used. We usually stick to medication management…We start with the simple things like an SSRI or an SNRI… and then we augment, but then what happens after we augment with multiple medications? The STAR*D trial actually showed us a very valuable lesson, and that is, we want to hit it hard from the very beginning.

So now we are looking at other modalities. Interventional psychiatry is coming into its own. We started with ECT, and it became kind of nasty because of One Flew Over the Cuckoo's Nest. But, no, we don't do that. Then we have the advent of…transcranial magnetic stimulation, which is now one of the mainstays of interventional psychiatry.

We are also going to be talking about vagal nerve stimulation, which is now becoming a mainstay treatment, albeit…expensive, but incredibly effective, and we use things like ketamine, s-ketamine, and things of that nature. So again, we're not confined to only one modality.

I always tell my patients, all right, you have 2 types of situations here. You have a biological nature or genesis of your depression. You have a psychosocial genesis of your depression. And guess what? We need to address what's happening in your life because all the medication or all the interventions in the world are not going to help you unless you figure out that you need to grieve.

HCPLive: Are there any new or emerging medications you’re particularly excited about?

Alva: There’s so many different things that are happening. We went from the monoamine theory, which was the mainstay of treatment for many years. Now we are looking at GABA receptors. We're looking at GABA modulators…glutamate modulators…muscarinic receptor agonists or antagonist as well.

There are a number of different medications [in] the pipeline. It’s an exciting time because now we have 2 options. We can go with the monoamines, or we can go with either muscarinic or…different modulators. We are making inroads into different modalities.

HCPLive: With so many innovations in psychiatry today, how can clinicians stay current and involved in advancing care?

Alva: A very easy way to stay up to date is conferences like this. It's fun because you meet new colleagues…If you do it in person, I would highly recommend it, because you run into incredible, amazing people that are very willing to compart their knowledge. The most important thing is that you have a free, open exchange of ideas.

The second thing is, stay current. There's so many publications, both written and online, so just look at what you have available. Keep up on the current theories and the current medications, and, more importantly, talk to your peers.