Considerations When Prescribing Medications Associated with Medication-Induced Movement Disorders (MIMDs)

Patients are treated with antipsychotic medications across the full continuum. Treatment that includes the prescription of antipsychotic medication should always be done in-person or using video technologies. Audio-only telehealth platforms are insufficient to allow for a mental status examination and adequate assessments of movements. However, phone conversations in between visits to address questions or concerns are appropriate.

Remote Visit Assessment

When assessing patients remotely, clinicians who offer antipsychotic medication treatment must have a plan to assess for abnormal movements and conduct screenings, such as the Abnormal Involuntary Movement Scale (AIMS). Possibilities include teaching (during an in-person visit) a trustworthy friend or family member how to report physical signs, partnering with a colleague available for in-person visits, asking for a clinic staff member to be present with the patient during the visit, or utilizing home-based services. In cases of serious reactions or concern for neuroleptic malignant syndrome (NMS) in an outpatient setting, referral to an emergency department is appropriate and requires direct communicationwith the ED physician.

Risk & Benefit Assessment: The Importance of a Good History

For all medication prescribing, it is critical to review the risks and benefits of the medication, assess if the patient understands the information, and pursue a shared decision-making approach whenever possible to align treatment with the patient's life goals. Taking a careful history of prior treatment to determine what medications have been previously effective or caused adverse reactions is critical to inform medication selection, initial dosing, and titration schedule. Obtaining collateral information from family, prior clinicians, and others is good clinical practice and may be required if the patient cannot give a detailed history

For individuals enrolled in Medicaid with a history of psychotropic medication or behavioral health service use, the history of prior treatment and treatment providers (with contact information) may be found in the Psychiatric Services and Clinical Knowledge Enhancement System (PSYCKES). PSYCKES is a secure, HIPAA-compliant web-based platform developed by OMH for sharing Medicaid billing claims and encounter data, health-related data, and other information entered by providers and patients. Organizations eligible to obtain access to PSYCKES include, but are not limited to, those that offer behavioral health services licensed by the NYS Office of Mental Health or certified by the NYS Office of Addiction Services and Supports, Federally Qualified Health Centers, and hospitals licensed by the NYS Department of Health. For information on obtaining access to PSYCKES, see this Protocol for PSYCKES access.

Diagnostic Considerations

Misdiagnosis of psychiatric illness results in patients receiving the wrong treatment, which exposes them to adverse reactions without providing benefit. To avoid misdiagnosis, clinicians must verify prior diagnoses by conducting a systematic differential diagnosis. Since studies of medication treatments used inclusion criteria based on the Diagnostic and Statistical Manual of Mental Disorders (DSM), it is important to follow this diagnostic rubric in clinical practice. Clinicians must use the history of present illness, clinical history, examination, and collateral information to determine that necessary criteria, including duration criteria, are met before giving a diagnosis. Exclusionary criteria, such as current or recent substance use, neurologic or other medical illness, and other psychiatric illness must be accounted for before a diagnosis is made.

Medical Bias

Clinicians need to be aware of their own biases when diagnosing patients with behavioral concerns, especially for those with aggressive behaviors. For example, Black men are more likely than white men to have been misdiagnosed with schizophrenia when their presentation is more consistent with posttraumatic stress disorder, major depressive disorder, or bipolar disorder. This pattern of misdiagnosis is a result of implicit bias – the prejudiced perception, that Black men and that people with schizophrenia are "scary," contribute to this outcome. If misdiagnosed, individuals do not get the appropriate treatment and risk developing adverse reactions to the incorrect treatment.

Pharmacological Considerations in Treatment of Psychiatric Disorders

Clinicians should be familiar with medications' mechanisms of action and avoid redundant polypharmacy. For example, if an individual is on a high dose of a potent dopamine 2 (D2)-receptor antagonist, there will be no benefit to adding a second similar medication. If someone is on a low dose of a medication, it is preferable to titrate the dose instead of adding another medication with a similar mechanism. Treating clinicians must ask their patients about adverse reactions and screen for them in mental status and physical examinations and through laboratory or other testing. Further, patients with other comorbidities may require a more complicated medication regimen and should be monitored for drug-drug interactions that may reduce the benefit of treatment or increase the risk of side effects.