Akathisia

Akathisia – Treatment Options

Introduction
Akathisia is a movement disorder characterized by an inner sense of restlessness and an uncontrollable urge to move, often presenting with pacing, shifting weight, or inability to sit still. It is most commonly associated with the use of antipsychotic medications (especially high-potency first-generation agents like haloperidol), but may also occur with SSRIs, SNRIs, antiemetics (metoclopramide, prochlorperazine), or withdrawal from dopaminergic drugs. It is distressing to patients, often mistaken for agitation or anxiety, and may contribute to poor treatment adherence or suicidal ideation. Early recognition and tailored treatment are essential.

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1. Modification of Causative Medication

• Dose reduction of the offending antipsychotic or antidepressant if clinically possible.

• Switching to an alternative agent with a lower risk of akathisia:

  • For antipsychotics: quetiapine, clozapine, or olanzapine may be safer choices.

• Slow titration when introducing new psychotropic medications.

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2. Pharmacological Treatments

• Beta-Blockers (First-Line)

  • Propranolol is the most widely used.

  • Dose: 20–120 mg/day in divided doses.

  • Effective in reducing restlessness and subjective discomfort.

• Anticholinergic Agents

  • Benztropine (1–4 mg/day) or trihexyphenidyl may help, particularly when akathisia coexists with parkinsonism.

  • Less effective for pure akathisia compared to propranolol.

• Benzodiazepines

  • Lorazepam, clonazepam, diazepam can relieve restlessness and anxiety.

  • Useful for short-term management; risk of dependence limits long-term use.

• Serotonin Antagonists

  • Mirtazapine (15–30 mg at night) and cyproheptadine (8–16 mg/day) have shown benefit, especially in antidepressant-induced akathisia.

• Other agents (refractory cases):

  • Amantadine, clonidine, gabapentin, pregabalin have been reported to help in select cases.

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3. Non-Pharmacological Approaches

• Patient education: Reassurance that the symptoms are drug-related and treatable.

• Supportive measures: Relaxation techniques, structured activity to reduce distress.

• Monitoring: Regular assessment with validated scales (e.g., Barnes Akathisia Rating Scale).

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4. Long-Term Management

• Aim for lowest effective dose of causative medication.

• Regular monitoring when initiating or increasing doses of high-risk drugs.

• Multidisciplinary care: Involvement of psychiatry, neurology, and primary care for optimal management.