The following case study was provided by Stanley N. Caroff, MD, professor of psychiatry at the University of Pennsylvania Perelman School of Medicine and the Corporal Michael J. Crescenz VA Medical Center in Philadelphia, Pennslyvania. Dr Caroff recently wrote a review on this topic, which was published in Neuropsychiatric Disease and Treatment.

A 62-year-old woman presented to her psychiatrist for treatment of depressed mood without suicidal ideation.  Following assessment, the patient was started on treatment with escitalopram 10 mg/d in addition to supportive psychotherapy. Her medical history was significant for type 2 diabetes well controlled with medication.  She reported no other personal or family history of medical, psychiatric, or neurologic disorders.

After a few weeks of partial response to treatment with the antidepressant, the dosage of escitalopram was increased to 20 mg/d. At a subsequent visit, the patient agreed to begin adjunctive treatment with aripiprazole 2 mg/d, with dose titration up to 10 mg/d.

The patient’s symptoms of depression continued to improve while she remained on stables doses of both the antidepressant and the antipsychotic. Treatment with aripiprazole was tolerated except for a rhythmic parkinsonian tremor of her hands at rest, which was managed initially with benztropine 2 mg given in 2 divided doses daily. She later complained of dry mouth and blurry vision; therefore, benztropine was discontinued, and the dose of aripiprizole was reduced to 5 mg.  Following treatment modification, the patient reported resolution of the tremor.


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Approximately one month later, the patient’s husband noticed she was making repetitive chewing movements and repeatedly asked her if she were chewing gum. She then began to notice these movements herself and became increasingly self-conscious and embarrassed, leading her to avoid leaving the house and refusing to attend social gatherings.

On a subsequent clinic visit, a formal examination with the Abnormal Involuntary Movement Scale (AIMS) revealed mild to moderate choreiform movements of her fingers in addition to the stereotyped chewing movements of her jaw and lips. She did not wear dentures and reported no problems with dentition. Physical examination and routine laboratory screening revealed no other abnormalities.

After informed discussion with the patient and her husband, she chose to taper off the aripiprazole to determine whether early detection of tardive dyskinesia could lead to resolution of the movements. Although her mood remained stable on the antidepressant alone, the tardive dyskinesia movements initially worsened and then subsided but remained mild and persistent.

After another 3 months, the patient remained aware of her movements and agreed to start treatment with deutetrabenazine, a vesicular monoamine transporter 2 (VMAT2) inhibitor, at a dosage of 12 mg/d.

Two weeks after a brief titration period, the tardive dyskinesia movements were almost completely suppressed and no longer noticeable. The patient was greatly relieved, able to resume her normal social routine, and showed no evidence of suicidality, recurrent depression, or tremor. She remained stable and doing well on the antidepressant and the VMAT2 inhibitor 6 months later.

Reference

Caroff SN. Overcoming barriers to effective management of tardive dyskinesia. Neuropsychiatr Dis Treat. 2019;15:785‐794.