Patients With Tardive Dyskinesia Symptoms May Go Undiagnosed

Tardive dyskinesia (TD), a movement disorder that causes involuntary movements often triggered by antipsychotic exposure, has appeared in the DSM for decades. Despite advancements in diagnostic tools and treatments, TD still goes unrecognized in many cases.

“Tardive dyskinesia continues to be a prevalent and clinically significant condition, particularly among older adults, women, and long-term antipsychotic users across both the United States and international settings,” noted Mohsin Raza, MD, MSc, of UHS Dover Behavioral Health System in Delaware, and colleagues in StatPearls.

“Geographic variations in prevalence and recognition exist within healthcare systems, with underdiagnosis persisting despite the availability of improved assessment tools,” they pointed out.

Massive Gaps in Formal Diagnosis Rates

Few patients with mood disorders and TD symptoms meeting diagnostic criteria received a formal TD diagnosis, according to a recent analysis from the IMPACT-TD registry presented at the 2026 American Psychiatric Association (APA) annual meeting. The formal diagnosis rate was lowest for participants ages 18 to 29, at 23%; it rose to 35% for participants ages 30 to 39, 57% for those ages 40 to 49, and 47% for those 50 and older.

A significant delay in diagnosis was also identified in the registry data, as patients waited an average of more than 3.5 years to be formally diagnosed after their involuntary movements were first recognized.

Corroborating these findings, a 2025 retrospective study analyzed de-identified structured and semi-structured EHR data. Of 1,301 patients who had evidence of TD during their mental state examination, only 64 (4.9%) received an ICD diagnosis of TD according to their records.

“Lack of a TD diagnosis in 95% of patients with evidence of abnormal movements associated with TD could represent a substantial missed opportunity for appropriate diagnosis and related evidence-based treatment,” Kira Griffiths, PhD, of Holmusk Technologies in London, and colleagues wrote in BMC Psychiatry.

The findings “suggest that evidence of abnormal movements and presence of TD is more frequently reported in clinical notes than in structured diagnostic EHR data,” they continued. “Results support previous research to show an underreporting of TD in real-world datasets and support [the] need to better recognize and document symptoms, given [the availability] of evidence-based and FDA-approved therapies for TD.”

Griffiths and co-authors found Black/African-American patients had lower odds of an ICD diagnosis compared with white individuals (OR 0.46, 95% CI 0.20-0.95, P=0.04). Conversely, treatment in community mental health centers was tied to increased odds of an ICD diagnosis compared with treatment at an academic medical center (adjusted OR 2.02, 95% CI 1.09-3.74, P=0.03).

In another retrospective analysis, this time looking at long-term care facility residents, 5.6% of patients being treated with antipsychotic drugs had an extrapyramidal syndrome diagnosis — a broad term used to describe any drug-induced movement disorder — while only 1.1% had a specific TD diagnosis. Less than half of those with a TD diagnosis were treated with a VMAT2 inhibitor, though APA practice guidelines recommend VMAT2 inhibitors for patients who have moderate-to-severe or disabling TD associated with antipsychotic therapy.

“Tardive dyskinesia remains a challenge to identify and is often mistaken for other conditions resulting in undertreatment or inappropriate treatment, often because of confusion about the symptoms a patient is having and also around appropriate treatment options,” commented Amita Patel, MD, MHA, of Joint Township Memorial Hospital in Dayton, Ohio, in a press release about the study. “These findings underscore the need to better understand and address the gaps in care that exist for residents in long-term care.”

Milder Symptoms Frequently Overlooked

Most patients who develop TD experience mild symptoms according to APA guidelines, and it may be easier for clinicians to miss some cases.

For example, in a study of 101 psychiatric inpatients, researchers identified tardive dyskinesia or related symptoms in 28% of cases while resident physicians only identified it in 11% of cases.

“Residents tended to miss milder cases of TD, and to miss DIP [drug-induced parkinsonism] in younger patients and in patients with affective disorders,” noted Thomas Hansen, MD, of Portland VA Medical Center in Oregon, and co-authors in General Hospital Psychiatry. “Improved teaching and clinical exams are recommended to improve recognition.”

Symptoms of TD can be “difficult to recognize and diagnose” as they can be “subtle and fluctuating, often have an insidious onset, and can easily be mistaken for symptoms of the patient’s mental disorder,” added Christoph Correll, MD, of the Zucker School of Medicine at Hofstra/Northwell in New York City, and Rakesh Jain, MD, MPH, of Texas Tech University School of Medicine in Midland, in the Journal of Clinical Psychiatry.

“Tardive dyskinesia remains a very real problem, and clinicians must be proactive to enable their patients to both recover from their psychiatric illnesses and remain free from this serious and potentially irreversible movement disorder,” said Correll and Jain.

“These goals can be accomplished by assessing patients for signs of movement disorders at baseline and throughout treatment, screening patients for TD risk factors, and using reliable rating scales and diagnostic criteria to identify this disorder as early as possible,” the duo advised.