What is the treatment for Akathisia (involuntary movement disorder)?

From the Guidelines

The most effective treatment for akathisia is to lower the dosage of the antipsychotic medication, switch to another antipsychotic medication, add a benzodiazepine medication, or add a beta-adrenergic blocking agent, as suggested by the American Psychiatric Association 1. When treating akathisia, it is essential to consider the underlying cause of the condition, which is often associated with antipsychotic therapy. The treatment approach should prioritize reducing morbidity, mortality, and improving quality of life.

• Reducing or discontinuing the offending medication is a crucial step in managing akathisia.
• Beta-blockers, such as propranolol, can be effective in reducing restlessness without affecting psychiatric symptoms.
• Anticholinergic medications, like benztropine or diphenhydramine, may also be useful in treating akathisia.
• Benzodiazepines, such as lorazepam, can provide short-term relief while other treatments take effect. The American Psychiatric Association recommends that patients with akathisia associated with antipsychotic therapy be treated with one of the following options: lowering the dosage of the antipsychotic medication, switching to another antipsychotic medication, adding a benzodiazepine medication, or adding a beta-adrenergic blocking agent 1. In contrast, an older study from the American Academy of Child and Adolescent Psychiatry suggests that antiparkinsonian agents are not consistently helpful in treating akathisia, although relief has been reported with β-blockers and benzodiazepines 1. However, the more recent and higher-quality study from the American Psychiatric Association 1 takes precedence in guiding treatment decisions for akathisia. Non-pharmacological approaches, such as relaxation techniques and physical activity, can also help manage symptoms and improve quality of life. Treatment should be individualized based on symptom severity, underlying conditions, and medication history.

From the Research

Treatment Options for Akathisia

• The treatment of akathisia typically involves the use of medications such as beta-blockers, anticholinergics, and benzodiazepines 2, 3, 4.
• Propranolol, a non-selective beta-adrenergic receptor antagonist, is currently considered a first-line treatment for antipsychotic-induced akathisia (AIA) 2, 5, 4.
• Low-dose mirtazapine has also demonstrated compelling evidence for therapeutic efficacy in the treatment of akathisia 5, 4.
• Other agents that have been investigated for the treatment of akathisia include ritanserin, piracetam, valproic acid, tricyclic antidepressants, and voltage-gated calcium channel blockers such as gabapentin and pregabalin 2, 3, 4.
• In some cases, discontinuation of the causative drug and use of symptomatic relief medications such as beta-blockers, mirtazapine, benzodiazepines, or gabapentinoids may be the basis of management 4.

Management of Akathisia

• The management of akathisia should first involve stopping the offending agent (if possible), lowering the dose, or changing to a lower potency neuroleptic 3.
• If these measures are not feasible, then other medications such as beta-blockers, anticholinergics, clonidine, or benzodiazepines can be tried 2, 3.
• Rotation between different pharmacological management strategies may be optimal in resistant cases 4.
• A high index of suspicion should be maintained in patients with motor disabilities, drug-induced parkinsonism, and those under mechanical restraint 4.

Pathophysiology and Clinical Presentation

• Akathisia is attributed to an imbalance between dopaminergic and noradrenergic neurotransmission in the basal ganglia 4.
• It is experienced as severe restlessness commonly accompanied by dysphoria and purposeless movement which relieves subjective tension 4.
• Akathisia can be a quite common and very troubling side effect of psychotropic treatment, and it limits treatment adherence 3, 4.