Perceptions on the diagnosis and treatment of patients with tardive dyskinesia: a cross-sectional survey among physicians in Italy

VASSILIS MARTIADIS1, ANGELO ANTONINI2,3, ANTONELLO BELLOMO4, ALESSANDRO CUOMO5, GIANCARLO CERVERI6, RITA ALLEGRETTI7, MARTINA PETRACCA8, GIACOMO DESTE9,10, TOMMASO B. JANNINI11, VALERIO DELL’OSTE12,13, ILARIA DI VICO14, MARIO CEPPARULO15

1Department of Mental Health, Local Health Authority Naples 1 Center, Naples, Italy; 2Neurodegenerative Disease Unit, Department of Neuroscience, University of Padova, Italy; 3IRCCS San Camillo Venice, Italy; 4Department of Biomedical Science, University of Foggia, Italy; 5Department of Molecular & Developmental Medicine, University of Siena, Italy; 6Department of Mental Health and Addiction, Local Health Authority of the Province of Lodi, Italy; 7Department of Neurosciences, Imaging and Clinical Sciences, G. D’Annunzio University of Chieti, Italy; 8Neurology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; 9Department of Mental Health and Addiction Services, ASST Valcamonica, Esine, Italy; 10Department of Clinical and Experimental Sciences, University of Brescia, Italy; 11Department of Experimental Medicine, Tor Vergata University of Rome, Italy; 12Department of Clinical and Experimental Medicine, University of Pisa, Italy; 13Department of Mental Health and Addiction, Azienda USL Toscana Nord-Ovest, Lucca, Italy; 14Neurology Unit, Department of Neurosciences, Biomedicine and Movement Sciences, Borgo Roma Hospital, University of Verona, Italy; 15Teva Italia Srl, Milan, Italy.

Summary. Background. This survey aimed to investigate how physicians in Italy recognize, diagnose, and manage tardive dyskinesia (TD), as well as to assess and identify gaps in the current treatment approaches. Methods. A non-interventional cross-sectional online survey was conducted among Italian physicians who had managed patients with TD in the 1 year prior to the survey. The questionnaire explored physicians’ demographics, clinical experience, diagnostic methods, treatment strategies, perceptions of TD impact, and health care resource utilization related to TD. Data were summarized descriptively. Results. The survey included 70 psychiatrists and 30 movement disorder neurologists. Most patients presented with mild (49%) or moderate (35%) TD. Treatment strategies varied by TD severity; antipsychotic dose modification or switching was common, particularly to clozapine, quetiapine, and aripiprazole, whereas TD-specific add-on treatments such as tetrabenazine were rarely used (12% to 21% of physicians prescribed the treatment). Movement impairment was primarily assessed through patient or caregiver reports on quality-of-life impact, while standardized scales like the Abnormal Involuntary Movement Scale were underused, especially by psychiatrists. Physicians acknowledged significant challenges including a lack of highly effective treatments and an absence of specific Italian or European guidelines. TD was perceived as significantly affecting patients’ physical and psychosocial functioning and increasing health care resource utilization. Conclusions. This study highlights variability and unmet needs in TD diagnosis and management among Italian specialists. Add-on treatments such as tetrabenazine are not considered standard of care in Italy due to lack of clinical practice guidelines, concerns around drug efficacy, adverse events, and overall treatment satisfaction.

Key words. Add-on treatment, movement disorder neurologists, psychiatrists, survey, tardive dyskinesia.

Percezione della diagnosi e del trattamento dei pazienti con discinesia tardiva: un’indagine tra psichiatri e neurologi in Italia.

Riassunto. Introduzione. L’indagine mirava a valutare come i medici in Italia riconoscono, diagnosticano e gestiscono la discinesia tardiva (TD) e a identificare le principali lacune negli attuali approcci terapeutici. Metodi. È stata condotta un’indagine online trasversale tra medici specialisti (psichiatri e neurologi esperti dei disturbi del movimento) italiani che avevano gestito pazienti con TD nell’anno precedente. Il questionario ha esplorato dati demografici, esperienza clinica, metodi diagnostici, strategie terapeutiche, percezioni dell’impatto della TD e utilizzo delle risorse sanitarie. I dati sono stati analizzati in modo descrittivo. Risultati. Hanno partecipato 70 psichiatri e 30 neurologi esperti dei disturbi del movimento. La maggior parte dei pazienti presentava TD lieve (49%) o moderata (35%). Si adottavano strategie terapeutiche diverse in base alla gravità della TD; la modifica del dosaggio degli antipsicotici o il passaggio a clozapina, quetiapina o aripiprazolo erano frequenti, mentre i trattamenti aggiuntivi specifici per la TD, come tetrabenazina, erano raramente impiegati (12-21% dei medici). Il disturbo motorio veniva valutato soprattutto tramite le segnalazioni di pazienti o caregiver sull’impatto della qualità della vita, mentre le scale standardizzate come l’Abnormal Involuntary Movement Scale erano poco utilizzate, in particolare dagli psichiatri. Tra le principali criticità figuravano la mancanza di trattamenti altamente efficaci e l’assenza di linee guida italiane o europee. La TD era percepita come fortemente impattante sul funzionamento fisico e psicosociale e sull’utilizzo delle risorse sanitarie. Conclusioni. Lo studio evidenzia variabilità e bisogni insoddisfatti nella diagnosi e gestione della TD. I trattamenti specifici, come la tetrabenazina, non sono considerati uno standard terapeutico in Italia per la mancanza di linee guida, dubbi sull’efficacia, eventi avversi e limitata soddisfazione clinica.

Parole chiave. Discinesia tardiva, indagine survey, neurologi esperti in disturbi del movimento, psichiatri, terapia aggiuntiva.

Introduction

Tardive dyskinesia (TD) is an often-irreversible hyperkinetic movement disorder and is characterized by stereotypical movements, chorea, athetosis, dystonia, akathisia, and other tic-like features. It mostly affects the orofacial region but may also affect muscles of the trunk, limbs, and head1,2. TD is a delayed-onset drug-induced disorder that may manifest months to years after the use of antipsychotic treatment or other dopamine receptor blocking agents3,4.

The estimated prevalence of TD among patients with chronic exposure to antipsychotics is 20%-30% globally and 22.3% in Europe3. First-generation antipsychotics (FGAs) are associated with the highest risk for TD (30% prevalence); however, this condition can also affect patients with exposure to second-generation antipsychotics (SGAs [21% prevalence])3,5. Other patient-related risk factors for TD development include older age, female sex, medical comorbidities such as diabetes, and substance use4.

TD can substantially affect a patient’s ability to perform activities of daily living and overall quality of life6,7 and has a negative effect on the quality of life of patients’ caregivers8. TD can also undermine treatment adherence and therefore increase the risk of relapse in underlying psychiatric conditions and is associated with higher healthcare resource utilization (HCRU) and costs9-11.

Despite its prevalence and impact, TD remains underdiagnosed and inconsistently treated in real-world clinical practice12. Additionally, there are no clear Italian or European guidelines for the treatment of patients with TD13, and TD-specific clinical practice guidelines are limited in countries outside of North America and Japan14-16. Treatments for TD include vesicular-monoamine transporter 2 inhibitors and other non-TD-specific agents, although most are still not approved by European regulatory agencies17. Tetrabenazine is the only TD-specific pharmacological treatment approved for use in moderate to severe TD in Italy13,18. Furthermore, there is significant variability across regions and specialties regarding who should lead TD management.

Physicians’ perspectives are crucial to inform the development of context-specific clinical guidelines, particularly in settings lacking standardized recommendations, by highlighting real-world challenges in TD management. International data on the perceptions of physicians toward TD prevention, diagnosis, management and treatment are limited in European countries, including Italy, where there is no defined protocol for managing and treating patients with TD. Understanding physicians’ real-world attitudes and heterogeneous practices is essential to identify barriers to early recognition and optimal treatment of patients with TD.

Therefore, the aim of this survey was to describe how physicians in Italy recognize TD, assess movement severity (including use of structured tools), and manage TD in routine clinical practice, including antipsychotic modification strategies and the use of add-on therapies. In addition, the survey explored key drivers of clinical decision-making and descriptively compared practices between psychiatrists and movement disorder neurologists (MDNs), given potential differences in training, clinical setting, and referral pathways.

Methods

Study design

This was a non-interventional cross-sectional survey of physicians who have managed patients with TD in the 1 year before the survey (2024-2025) and was developed by Oracle Life Sciences. This survey formed part of a broader cross-sectional study conducted across several European countries and the UK, with an overall target sample of 400 physicians. A total of 368 physicians completed the survey across participating countries. Physicians were recruited through professional panels and databases managed by Oracle Life Sciences. Cognitive interview pre-tests with 3 specialists per country were conducted to ensure correct interpretation of the survey content. Pre-tests took place in France, Italy, Spain, and the UK. Feedback from the pre-tests was reviewed to develop the final survey. The results of this survey focused on the characteristics and treatment patterns of physicians in Italy as well as physician perceptions of the diagnosis, management, and attitudes toward TD. Physicians received an initial survey by email to assess eligibility criteria for the study. Eligible physicians were directed to a 30-minute online questionnaire. The survey underwent a pilot phase and interview pretests were performed with 3 physicians per European country. Of the total respondents, 100 physicians were practicing in Italy and are included in the present country-specific analysis. Country-level invitation and response rate data were not available.

Population

A total of 100 Italian physicians were included in the final analysis for this study. Physicians were psychiatrists or MDNs and were required to have been in practice ≥3 years, spend ≥60% of their time in direct patient care, have ≥3 patients with TD under their care in the 1 year before the survey, and have treated ≥100 patients with schizophrenia, schizoaffective disorder, major depressive disorder, or bipolar disorder in the preceding year.

Objectives

The key primary objectives were to understand how physicians diagnose patients with TD and assess movement severity; to understand differences between specialists in their diagnosis, management, and treatment of TD; and to understand physicians’ strategies when treating patients with TD. Symptom severity was assessed with the Abnormal Involuntary Movement Scale (AIMS). An AIMS score of ≥2 in 2 or more body areas or a score of 3 or 4 in at least 1 body region indicates abnormal hyperkinetic movements associated with TD. Mild TD was defined by an AIMS motor score of <6, while moderate TD and severe TD were defined by AIMS motor scores of 6-14 and >14, respectively. These severity definitions were provided within the questionnaire, and respondents were asked to classify patients according to these thresholds based on their clinical judgment and/or use of AIMS in routine practice; individual patient-level AIMS scores were not centrally verified. Add-on treatments for TD refer to treatments used in addition to the antipsychotic prescribed for the underlying psychiatric disorder. These include TD non-specific therapies such as anticholinergics and benzodiazepines, and TD-specific therapies such as tetrabenazine.

Other objectives were to assess physicians’ attitudes toward TD, its effect on patients’ quality of life, and physicians’ perceptions of HCRU by patients in the last year.

Statistical analysis

Data were summarized descriptively with SAS 9.4. Means and standard deviations were reported for continuous variables and frequencies and percentages were reported for categorical variables. Data were checked for missing or anomalous values and survey responses were validated internally.

Results

Physician-reported TD severity and diagnosis

A total of 100 physicians from different regions in Italy, including 30 MDNs and 70 psychiatrists, were surveyed (table 1).




Most physicians reported that patients were diagnosed with mild (49.1% [SD: 23.2]) or moderate (34.6% [15.7]) TD in the past year, while severe TD accounted for 16.3% (12.0) of overall diagnoses (figure 1A). Abnormal movement severity was primarily assessed by asking patients or caregivers about the effect of movements on the patients’ quality of life (figure 1B). The Schooler-Kane criteria were never/rarely used by 80.4% of physicians with AIMS, never/rarely used by 50.0% of psychiatrists, and often/always used by 48.3% of neurologists. Among patients with TD, symptoms were mostly assessed at each consultation by 28.0% and every 2-3 months by 22.0% of physicians (figure 1C).




Description of TD management by physicians

In patients with mild TD, tetrabenazine use was reported by only 12.3% (SD: 17.7) of physicians, while 35.0% (24.7) of physicians reported using benzodiazepines and 32.0% (27.0) reported using anticholinergics as add-on treatments for TD. Many physicians adopted a strategy of dose modification/interruption/switch of the antipsychotic, but there was also a significant proportion of physicians (30.2% [27.3]) who did not intervene, applying a wait-and-see approach (i.e., only monitoring symptoms) (figure 2).




The most common therapeutic strategy was to reduce the dose of the antipsychotic (44.3% [24.4] of physicians); discontinuation of antipsychotic treatment was relatively rare (14.7% [17.2]). Antipsychotic switching was adopted in 36.4% (22.8) of cases; clozapine, aripiprazole, and quetiapine were the most common antipsychotics to which patients were switched.

In patients with moderate TD, there was a slight increase in the use of TD-specific add-on therapies such as tetrabenazine (17.0% [18.7]), when compared with the management of mild TD. The use of non-TD-specific add-on treatments such as anticholinergics and benzodiazepines was observed in one-third of cases (36.4% [19.4]). The most common therapeutic strategy was the modification of antipsychotic therapy (50.7% [22.6] of physicians), while the proportion of patients for whom a wait-and-see strategy was adopted was less than for those with mild TD (13.0% [16.0]) (figure 2).

For severe TD, tetrabenazine was prescribed in 20.7% [20.2] of cases, which was more than was prescribed for mild and moderate TD. The proportion of physicians who prescribed anticholinergics as an add-on treatment for severe TD (29.4% [26.7]) was less than those who prescribed for mild and moderate TD. Even so, modifying the antipsychotic therapy remained the most common therapeutic strategy (53.0% [22.9] of physicians) (figure 2). The practice of switching between antipsychotic drugs increased (47.6% [29.5] of physicians) in cases of severe TD, while the proportion of psychiatrists who discontinued antipsychotic treatment (24.6% [27.9]) was more than those who discontinued antipsychotics for patients with mild and moderate forms of TD. Among psychiatrists who switched between different antipsychotics, the predominant choice for severe TD remained clozapine (32.6% [27.8]), followed by antipsychotics such as quetiapine (21.2% [19.3]) and aripiprazole (18.7% [22.1]). When physicians were asked about the safety and efficacy of different add-on treatments for patients with TD, the different treatments were scored similarly (figure 3), and none scored higher than 8 on efficacy or safety.




Physicians’ perceptions of TD management strategies

The main reason physicians started treatment for TD was because of its effect on the patient’s physical and psychosocial functioning (79.0% and 77.0% of physicians, respectively). However, only 50.0% of psychiatrists reported that the impact of TD on a patient’s underlying psychiatric condition was a motivating factor for initiating treatment (figure 4A). Among the reasons reported by physicians for not treating patients with TD with TD-specific therapies such as tetrabenazine, 42.0% and 39.5% believed that modifying antipsychotic therapy (dose reduction/interruption/switching) and the wait-and-see strategy, respectively, were sufficient/adequate to achieve control of TD symptoms (figure 4B). Regarding factors that influence TD treatment strategies, the severity of TD (for 81.0% of physicians) and its impact on a patient’s quality of life (70.0%) were the highest priorities among physicians (figure 4C). The survey revealed some significant gaps in patient treatment, especially surrounding the lack of highly effective treatments and specific guidelines in Europe and Italy (figure 4D).




Physicians’ attitudes toward TD

Physicians largely agreed that TD is an important/severe condition (76.0% of physicians) and not a rare disorder (87.0%). Although most responding physicians believed that the management of TD is time consuming (62.0%) and complex (83.0%), the majority (77.0%) agreed that treatment is a priority.

Physicians’ perceptions on the impact of TD on patients’ quality of life

Physicians rated the impact of TD on patients’ quality of life higher with more severe TD. On a scale of 1-10, mean impact was rated 9.3 (SD: 0.9) for severe TD, 7.6 (1.2) for moderate TD, and 6.1 (1.6) for mild TD.

Physicians’ perceptions on HCRU in patients with TD

About 49.0% of physicians agreed that patients with TD visit general practitioners more than patients without TD, but with the same underlying psychiatric conditions. Most physicians (71.0%) agreed that patients with TD use additional consultation time in office visits compared with patients without TD, but with the same underlying psychiatric conditions, and that patients with TD have additional costs compared with patients without TD, but with the same underlying psychiatric conditions (64.0%). Of patients with a caregiver (64.9% [SD: 22.2]), 59.4% [24.4] were cared for by a spouse, relative, or friend, 14.7% [15.5] by a paid assistant, 18.8% [16.9] by an assisted living facility caregiver, and for 7.2% [20.6] the caregiver was unknown.

Discussion

In this survey, psychiatrists and MDNs reported on the severity and onset, diagnosis, management, and treatment strategies for patients with TD. Additionally, their perceptions and attitudes toward TD were also assessed. Most physicians reported on varied strategies for treating patients with TD and agreed that treating TD is a priority, even though it can be a time-consuming and complex process. This study provides, to our knowledge, the first systematic insight into real-world TD recognition and treatment practices among Italian neurologists and psychiatrists, highlighting key differences and unmet needs. Because these findings are based on self-reported practices, differences between psychiatrists and MDNs should be interpreted cautiously. Observed variability may reflect contextual factors, including differences in clinical setting (e.g., outpatient vs academic centers), referral pathways, case complexity, and access to specialized movement disorder expertise, in addition to differences in clinical decision-making.

No significant differences were found in perceived safety or efficacy scores among TD add-on treatments including tetrabenazine, benzodiazepines, and anticholinergics. Despite being approved for TD, tetrabenazine only received a level C recommendation from the American Academy of Neurology due to limited supporting evidence19. Its use is further complicated by adverse events (e.g. akathisia and parkinsonism), and complex daily scheduling, because of its pharmacokinetic profile20. Furthermore, although it is approved in European countries (including Italy)13,20 for the treatment of TD, tetrabenazine is not considered standard of care for TD in Italy. Therefore, tetrabenazine adoption in Italy is poor, and Italian physicians are reluctant to consider it as a first-line treatment. Even so, the need for a TD treatment has necessitated endorsement of tetrabenazine (even with limited clinical evidence and safety issues) by the Italian Medicines Agency. Notably, a survey conducted among Australian and Israeli physicians has also highlighted their dissatisfaction with tetrabenazine, especially in its failure to reach optimal clinical effects due to patient discontinuation and side effects21.

EU guidelines recommend optimizing antipsychotic treatment before prescribing add-on TD-specific treatments13. A common strategy, especially for mild to moderate TD was antipsychotic switching. In patients with major depressive disorder (MDD) or bipolar disorder (BD), reducing or discontinuing antipsychotics may be feasible by using alternatives like mood stabilizers or antidepressants. However, in schizophrenia, discontinuation is typically avoided due to relapse risk22, making switching a safer option to avoid symptom exacerbation15. Still, switching can lead to side effects or suboptimal responses due to differences in antipsychotic pharmacodynamic profiles23.

Although associated with movement disorders such as akathisia, SGAs clozapine and quetiapine were among the most frequently chosen antipsychotics for switching. Notably, switching from FGAs to SGAs does not necessarily guarantee improvement in psychotic symptoms19. Clozapine is frequently used by psychiatrists to treat patients with TD (especially patients with concomitant treatment-resistant schizophrenia), while some neurologists prefer quetiapine or phenothiazine. The different treatment approaches suggest that there is some variability in therapeutic choices, depending on individual experiences and patient preferences19.

For TD diagnosis, most psychiatrists and neurologists have reported the use of scales such as AIMS, though use was higher among neurologists. Twenty-five percent of psychiatrists reported routine use of this scale, which is likely an overestimation, reflecting the challenges of community-based care24, limited consultation time, lack of training, and access to resources, which could hinder standardized assessments. Clinical evaluation was the predominant diagnostic tool for assessing TD severity. While psychiatrists reported frequent symptom assessments (once every 2-3 months or at each consultation), this likely reflects response bias, as such frequency is rare in practice24. In contrast, 43% of MDNs assess symptoms every 4-6 months. Limited training, especially among psychiatrists, may also contribute to challenges in distinguishing TD from other movement disorders such as drug-induced parkinsonism25.

Although physician perspectives on the quality of life of patients with TD were not assessed in detail, physicians mostly agreed that more severe TD affects patients’ lives more significantly. Previous surveys on the impact of TD in countries outside Europe have also shown greater impact scores with increasing TD severity, as reported by patients and physicians11,26. Consistent with surveys performed in China, South Korea, Australia, and Brazil, physicians in this study reported that the impacts of TD on physical and social functioning were the main drivers for initiating treatment11. Because patients were primarily cared for by individuals close to them, the impact of TD on caregivers’ quality of life should also be factored into assessments of HCRU.

Physicians mostly agreed that management of TD was associated with higher HCRU and healthcare costs. A retrospective claims database analysis in the United States has also demonstrated that more inpatient admissions and emergency room visits occurred for patients with TD than for patients without TD9. Additionally, there was greater use of different TD non-specific add-on therapies (which is not always appropriate). Tetrabenazine, despite being licensed for TD in Italy, was underused even in cases of severe TD. National training programs, a consensus document, and decision-making algorithms for antipsychotic modification with respect to TD may promote consistency in clinical practice and provide clearer guidance for the treatment and management of TD.

From a practical standpoint, these findings highlight three key considerations for routine care, namely the importance of systematic monitoring for TD in patients receiving dopamine receptor-blocking agents, ideally incorporating structured tools such as AIMS; the need for clearer decision-making algorithms to guide antipsychotic modification versus initiation of add-on therapy such as tetrabenazine; and consideration of referral to movement disorder specialists in complex or severe cases. Development of national consensus recommendations may help reduce variability in clinical practice and improve patient care.

Limitations

As with any research relying on convenience sampling methods, there is the potential for selection bias. Most psychiatrist respondents were from outpatient settings, while neurologist respondents were from academic settings. As the survey was designed to recruit specialists, the generalizability of the findings to a broader population is limited. Of note, country-specific invitation and response rate data were not available, and therefore the representativeness of the Italian sample relative to all eligible specialists cannot be fully assessed. Additionally, participation in the study was dependent on physicians’ ability and recall bias, with the quality of data depending on accurate reporting of information. It is important to note that many psychiatrists report discomfort with the diagnosis and management of TD, which may have introduced bias into the results. Differences in practice setting, including the concentration of psychiatrists in outpatient settings and neurologists in academic centers, may also have influenced reported practices and may limit generalizability to all Italian clinicians managing TD. There was also no control for confounding variables or regional differences in care.

Conclusions

These results demonstrate significant gaps in access to effective treatment options for TD in Italy. Furthermore, some clinicians consider adjustment of antipsychotic regimens (such as dose reduction and switching) or simply monitoring patients as approaches that are sufficient to control TD symptoms without add-on therapies, even though tetrabenazine is licensed for the use of TD treatment in Italy. Physicians are reluctant to use tetrabenazine, and it is not considered standard of care in Italy due to lack of clinical practice guidelines, concerns around drug efficacy, adverse events, and overall treatment satisfaction. Educational initiatives and better decision-making algorithms could promote consistency in clinical practice and provide better guidance for management of TD.

Funding/Support: Teva Branded Pharmaceutical Products R&D LLC.

Role of the Sponsor: the sponsor participated in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and funded the preparation of the manuscript. All authors, including those affiliated with the sponsor, fulfilled all authorship criteria and participated in the review and approval of the manuscript and in the decision to submit the manuscript for publication.

Acknowledgments: medical writing and editorial support were provided by Jean-Paul Fouche, PhD, Danielle Hirsch, PhD, CMPP, and Kathleen Blake, PhD, of Ashfield MedComms, an Inizio company, and was funded by Teva Branded Pharmaceutical Products R&D, LLC.

Statement on the use of artificial intelligence: a generative artificial intelligence tool (ChatGPT, OpenAI) was used to assist in translating the abstract from English to Italian. The authors have thoroughly reviewed, corrected, and approved the translated content and take full responsibility for the accuracy and integrity of the final text. ChatGPT did not contribute to scientific decisions, data analysis, or the formulation of any original content in the study.

Competing interests: Martiadis has received consultancy fees from Johnson & Johnson, Lundbeck, Otsuka, and Teva Italy. Antonini has received compensation for consultancy and speaker-related activities from AbbVie, Bayer, Bial, Britannia, Ever Pharma, Ferrer, Teva, Theravance Biopharma, UCB, and Zambon. He has also received research support from Horizon 2020 grants 825785 and 101016902, the Ministry of Education University and Research (MIUR) grant ARS01_01081, and the Fondazione Pezzoli per la Malattia di Parkinson. Cuomo has received honoraria, consultancy fees, or participated in speaker engagements, advisory boards, or research collaborations from Janssen, Lundbeck, Otsuka, Angelini Pharma, Neuraxpharm, Recordati, Teva, Gedeon Richter, AbbVie, Biogen, UCB Pharma, Sage Therapeutics, Takeda, Novartis, and Eli Lilly. Petracca has received fees for speaker-related activities from AbbVie, Bial, Ipsen, and Merz. She has also received research support from the Ministry of Health grant GR-2021-12374686. Deste received support (directly or indirectly) for clinical studies or trials, conferences, consultancies, congress presentations, advisory boards from Angelini, EG, and Italfarmaco. Dell’Oste has received fees for speaker-related activities from Neuraxpharm. Cepparulo is an employee of Teva Pharmaceuticals. Allegretti, Bellomo, Cerveri, Di Vico, and Jannini have no conflicts or reportable financial relationships to disclose.

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