Tardive dyskinesia risk is higher in people without schizophrenia, especially mood disorders, and clinicians underestimate it because antipsychotics are so easy to start. Use antipsychotics sparingly, keep aripiprazole low for depression, avoid abrupt stops, and know how to do a real AIMS.
Who is at risk
TD is permanent involuntary movements of the face, mouth or body from antipsychotic use. Giving antipsychotics to people without schizophrenia seems to raise the risk, and it is higher in mood disorders; whatever is going on in schizophrenia seems less vulnerable.
“It seems like giving antipsychotics to people without schizophrenia raises the risk of tardive dyskinesia”
45:42Anxiety Medications Tier List: The Best and Worst Treatments for GADJul 2026 Also said in 1 more episode
“Tardive dyskinesia, permanent involuntary movements of the face, mouth, or body that come from antipsychotic use. And it's higher risk in people with mood disorders. Interestingly, if you have a schizophrenia, whatever is going on with that seems to not be as vulnerable to tardive dyskinesia”
36:09The Best Bipolar Medication Review From The Best Bipolar ExpertJan 2025 Clinicians underestimate the risk because antipsychotic treatment is so easy: no labs, it works fast, and inpatient everyone gets one. The TD risk is higher in people without a primary psychotic disorder.
“clinicians are underestimating the risk of antipsychotic treatment because antipsychotic treatment is so easy. You don't have to draw labs and it works really fast, especially inpatient. So everyone gets antipsychotic. But they have side effects. And the risk of tardive dyskinesia is higher in people who don't have a primary psychotic disorder”
27:37What is Psychosis? Look at the DSM, Common Mimics, and a Framework for the DifferentialJan 2026 Chlorpromazine causes EPS and carries a high risk of tardive dyskinesia, which is part of why it is called first-generation.
“because chlorpromazine does hit the ham receptors. So it does have histaminergic alpha-1 and muscarinic problems. The reason why we call it first-gen is because it does also cause EPS. It does cause high risk of tardive dyskinesia”
1:07:36Antipsychotic Tier List: Ranking the Best and Worst Anti-psychoticsOct 2026
Preventing it
Use antipsychotics sparingly and only as the clinical picture needs. Abrupt withdrawal dyskinesias can happen, and they may go away or persist.
“You can get abrupt withdrawal dyskinesias that can go away or they can persist. A little scary. and it's definitely more likely to happen in people with mood disorders and have schizophrenia so please use your antipsychotics sparingly and only as needed for the clinical picture”
Choosing Antipsychotics in Schizophrenia: Side-Effects, Maximizing Efficacy, and Finding the Right Medication | Episode 17Feb 2025 Do not dose aripiprazole above 5 mg for major depression without psychotic features. It is not worth it.
“Do not dose-abilify above 5 mg if what you are trying to do is trying to treat major depressive disorder without psychotic features. Do not do it. Just don't do it. It's not worth it”
59:08Antidepressant Tier List: Psychiatrists Rank Depression Medications for MDDMay 2026 Choosing an antipsychotic is often a trade: sleepy, heavier and full of metabolic syndrome, or more tardive dyskinesia and more akathisia.
“You ask yourself, Do I want to be sleepy, fat, and full of metabolic syndrome? Or do I want to be developing more targeted dyskinesia and having more akathisia”
7:05Antipsychotic Tier List: Ranking the Best and Worst Anti-psychoticsOct 2026
Monitoring
Know how to do an AIMS: read the directions and actually do it. A modified AIMS can be done over video with help from a family member or a nurse.
“you should know how to do an AIMS. See the research. Read the AIMS. Read the AIMS. Read the directions and actually do an AIMS. And you can do a modified version of the AIMS over video if you have assistance from a family member or a nurse”
58:43Antidepressant Tier List: Psychiatrists Rank Depression Medications for MDDMay 2026
Pitfalls and myths
Schizophrenia has its own rate of movement disorders. Pre-antipsychotic studies show patients developing tardive dyskinesia anyway.
“schizophrenia has its own rate of movement disorders, okay, without antipsychotic use. If you look at pre-antipsychotic studies, they were already developing tardive dyskinesia anyway”
1:08:13Antipsychotic Tier List: Ranking the Best and Worst Anti-psychoticsOct 2026 Second-generation drugs may seem to cause less TD for two reasons: we use them at lower doses, and patients have been on them for less time than first-generation drugs.
“I think the reason why we think second generations have less of it is because we use lower doses of the second generations, and the patients were on the second generations for less time than the first generations, both reasons”
1:08:32Antipsychotic Tier List: Ranking the Best and Worst Anti-psychoticsOct 2026
It also comes up on
- AugmentationQuetiapine as an augmenter has lower tardive dyskinesia risk than the others and is very well tolerated, so well that it can be hard to get patients off it once they are stable.
- QuetiapineAs an antidepressant augmenter it has lower tardive dyskinesia risk than the other antipsychotics and is very well tolerated, so well tolerated that it can be hard to get patients off it once they are stable.
- AntipsychoticsMany antipsychotics are depressogenic and are not great long term, with bad metabolic effects and risks of EPS and tardive dyskinesia.
- Major depressive disorderMany antipsychotics are depressogenic and not great long term, with bad metabolic effects and risk of EPS and tardive dyskinesia.
- Metabolic side effectsPick weight-sparing medications when possible. That often trades for a risk of akathisia, or sometimes tardive dyskinesia with a first-generation drug.
From these episodes
- Antipsychotic Tier List: Ranking the Best and Worst Anti-psychoticsOct 2026 · 4 points
- Anxiety Medications Tier List: The Best and Worst Treatments for GADJul 2026 · 1 point
- Antidepressant Tier List: Psychiatrists Rank Depression Medications for MDDMay 2026 · 2 points
- What is Psychosis? Look at the DSM, Common Mimics, and a Framework for the DifferentialJan 2026 · 1 point
- Choosing Antipsychotics in Schizophrenia: Side-Effects, Maximizing Efficacy, and Finding the Right Medication | Episode 17Feb 2025 · 1 point
- The Best Bipolar Medication Review From The Best Bipolar ExpertJan 2025 · 1 point
Every point above is something said on the Psychofarm podcast, with the words as spoken and a link to the moment in the episode. It is education, not medical advice, and an episode reflects what we thought when we recorded it.