Tardive Dyskinesia Associated With Substantially Higher Healthcare Costs and Resource Use in Germany, Real-World Claims Analysis Finds

Patients with newly diagnosed tardive dyskinesia (TD) in Germany faced significantly higher healthcare utilization and costs compared with matched controls without TD, according to a retrospective claims analysis published in the Journal of Psychiatric Research.¹ The study also found that fewer than one-quarter of patients with TD received any approved treatment, and those who did had short treatment durations and poor adherence, underscoring a substantial real-world treatment gap in Germany.

Led by Christoph U. Correll, MD, of the Zucker Hillside Hospital at Northwell Health and the Charite Universitatsmedizin Berlin, the analysis drew on the Institute for Applied Health Research Berlin (InGef) database, a representative German claims database covering approximately 4 million patients. Among 3,236,637 continuously observable patients, only 389 adults met criteria for the overall TD population, a prevalence of 0.012%, which investigators noted is more than two- to threefold lower than real-world prevalence figures reported in the United States, consistent with recognized underdiagnosis of TD in Germany and in database studies globally.

The study was structured in two parts. Part 1 characterized the overall TD population, including incident (n = 199) and prevalent (n = 190) subgroups, across the study period 2016 to 2022. Part 2 compared healthcare resource utilization (HCRU) and costs between a propensity score-matched cohort of 145 patients with incident TD and 435 non-TD controls, all of whom had an underlying mental health diagnosis or antipsychotic or antiemetic use in the pre-index period.

The TD population skewed older and predominantly female, with a mean age of 67.2 years and 64.0% women. Major depressive disorder was the most common underlying psychiatric diagnosis (53.5%), followed by schizophrenia (33.9%) and schizotypal and delusional disorders (25.4%). Most index diagnoses were made in the outpatient setting, most often by a neurologist (38.0%) or general practitioner (28.3%).¹

Treatment patterns were strikingly limited. Only 21.1% of the overall TD population received either of the two approved treatments in Germany, tiapride or tetrabenazine. Among those who did, apparent treatment durations were under 1 year, and adherence, particularly to tiapride, was poor. Medication possession ratios of 0.8 or greater were achieved by only 18.8% of tiapride users versus 72.2% for tetrabenazine. Higher discontinuation rates were also observed with tiapride across all TD subgroups.¹ Notably, post-index healthcare costs were similar regardless of whether patients received an approved TD treatment, suggesting the available agents in Germany do not meaningfully reduce downstream healthcare burden.

In the matched analysis, the burden of incident TD was clear. Post-index all-cause hospitalizations occurred in 62.1% of the incident TD cohort versus 48.7% of non-TD controls (P = .01). Emergency department visits were recorded in 35.9% versus 25.1% (P = .01), and neurologist outpatient visits in 69.7% versus 40.5% (P < .001). Mean outpatient visits overall were higher in the TD group (33.9 vs 27.9; P < .01), as were mean prescriptions (25.4 vs 20.5; P < .01).¹

Mean annual all-cause healthcare costs in the post-index period were €13,176 for the incident TD cohort versus €7,288 for non-TD controls (P < .001), an 80.8% difference driven primarily by inpatient encounters. Pre-index costs were approximately equal between groups at around €9,000 each, indicating that the cost divergence emerged after TD diagnosis rather than reflecting pre-existing differences in illness severity.

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The investigators contextualized these findings against comparable data from the US and Israel, where annual per-patient healthcare costs were also significantly elevated in TD populations versus matched controls ($54,656 vs $28,777 in the US; $11,079 vs $7,145 in Israel). The German analysis showed a proportionately larger post-index cost increase (44.6%) than the US (26.2%), driven by a 78.7% rise in mean inpatient costs, which the authors attributed in part to longer inpatient stays in Germany versus the US.

The study highlights a clinical and pharmacological gap that is particularly acute in Europe. Neither tiapride nor tetrabenazine, the only approved TD treatments in Germany, has been evaluated in double-blind, randomized, placebo-controlled trials for TD, and evidence-based guidelines specific to TD in Germany are absent.

Two VMAT2 inhibitors with robust phase 3 evidence, deutetrabenazine (Austedo; Teva) and valbenazine (Ingrezza; Neurocrine Biosciences), are approved in the United States for TD based on the ARM-TD and KINECT-3 trials, respectively, and are recommended in current APA guidelines for moderate to severe or disabling TD.^2,3 Neither is currently approved in the European Union for this indication, leaving German clinicians without access to the most evidence-supported therapies available to their US counterparts.

Several limitations warrant consideration. The G24.0 ICD-10-GM code used to identify TD captures drug-induced dystonia broadly and is not specific for TD, introducing potential misclassification in both directions. Clinical severity data were not available in the claims database, preventing assessment of TD severity as a driver of costs. Small numbers of treated patients limit the interpretation of treatment duration and adherence data. Indirect costs related to lost productivity were not captured given the predominantly retired study population.

REFERENCES
1. Correll CU, Haas JS, Chaijale N, et al. Real-world patient characteristics, treatment patterns, and healthcare resource utilization and costs of tardive dyskinesia in Germany. J Psychiatr Res. 2026;200:112-122. doi:10.1016/j.jpsychires.2026.05.017. https://doi.org/10.1016/j.jpsychires.2026.05.017
2. Bhidayasiri R, Jitkritsadakul O, Friedman JH, Fahn S. Updating the recommendations for treatment of tardive syndromes: a systematic review of new evidence and practical treatment algorithm. J Neurol Sci. 2018;389:67-75. doi:10.1016/j.jns.2018.02.010. https://doi.org/10.1016/j.jns.2018.02.010
3. Keepers GA, Fochtmann LJ, Anzia JM, et al. The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia. Am J Psychiatry. 2020;177(9):868-872. doi:10.1176/appi.ajp.2020.177901. https://doi.org/10.1176/appi.ajp.2020.177901