What is the management of Akathisia in mental health?

Management of Akathisia in Mental Health

For patients with akathisia associated with antipsychotic therapy, the recommended management options include lowering the antipsychotic dose, switching to another antipsychotic medication, adding a benzodiazepine, or adding a beta-adrenergic blocking agent. 1

Understanding Akathisia

Akathisia is a distressing movement disorder characterized by:

• Subjective component: Inner restlessness and an urge to move
• Objective component: Repetitive movements such as rocking while standing/sitting, lifting feet as if marching, and crossing/uncrossing legs 2

It is one of the most common and distressing side effects of antipsychotic medications, with prevalence rates ranging from 5% to 36.8% 2. Akathisia can significantly impact treatment adherence and clinical outcomes, potentially leading to treatment discontinuation 3.

Clinical Presentation and Recognition

Akathisia can be classified according to onset timing:

• Acute akathisia: Occurs shortly after starting antipsychotic treatment
• Tardive akathisia: Develops after prolonged antipsychotic use
• Withdrawal akathisia: Appears when reducing or discontinuing antipsychotics
• Chronic akathisia: Persists for extended periods 2

Common presentations include:

• Pacing or physical agitation
• Rocking while standing or sitting
• Inability to sit still
• Crossing and uncrossing legs repeatedly
• Subjective feelings of restlessness that can be misinterpreted as anxiety or psychotic agitation 4

Important: Akathisia is often misdiagnosed as psychotic agitation or anxiety, leading to inappropriate increases in antipsychotic dosage that can worsen the condition 1.

Management Algorithm

First-line interventions:

1. Modify antipsychotic treatment:

   • Lower the dosage of the current antipsychotic medication 1
   • Switch to an antipsychotic with lower risk of akathisia 1
     • Consider iloperidone or asenapine, which have lower akathisia rates (3.9% and 6.8% respectively) compared to cariprazine (17.2%) 3

2. Add pharmacological treatment:

   • Beta-adrenergic blocking agents: Propranolol is the most consistently effective treatment 2
     • Typical dosage: 10-30 mg two to three times daily 1
     • Consider other lipophilic beta-blockers if propranolol is contraindicated
   • Benzodiazepines: Particularly useful when subjective distress persists 2

Second-line interventions (if first-line fails):

1. Add anticholinergic medication (for concurrent parkinsonian symptoms) 1
2. Consider amantadine or clonidine 2
3. Serotonin 5-HT2a receptor antagonists:
   • Mirtazapine (7.5-15 mg once daily) has shown compelling evidence for efficacy 5
   • Other options include cyproheptadine, trazodone, mianserin 5

Special Considerations

Risk factors to assess:

• Type of antipsychotic medication (first-generation antipsychotics carry higher risk)
• Higher antipsychotic doses
• Rapid dose escalation
• Previous history of akathisia
• Diagnosis (risk varies across schizophrenia, bipolar disorder, and major depression) 3

Monitoring:

• Regularly assess for akathisia using standardized scales (e.g., Barnes Akathisia Rating Scale)
• Monitor for akathisia when initiating or changing antipsychotic medications
• Pay special attention during the first few weeks of treatment

Common pitfalls to avoid:

1. Misdiagnosing akathisia as worsening psychosis or anxiety, leading to inappropriate dose increases
2. Overlooking the subjective component when objective movements are subtle
3. Failing to recognize akathisia as a cause of medication non-adherence
4. Not considering akathisia as a potential contributor to suicidal ideation or aggressive behavior 4
5. Assuming second-generation antipsychotics are devoid of akathisia effects - they still carry significant risk 6

Specific Medication Considerations

When using beta-blockers for akathisia:

• Monitor for hypotension and bradycardia
• Use with caution in patients with asthma, diabetes, or heart block
• Consider contraindications including severe respiratory depression, acute narrow-angle glaucoma, and concurrent alcohol intoxication 7

When considering benzodiazepines:

• Monitor for excessive sedation, respiratory depression, falls, and cognitive impairment
• Have flumazenil available for severe respiratory depression 7

Conclusion

Early recognition and appropriate management of akathisia are essential to improve treatment adherence and outcomes in patients receiving antipsychotic medications. The management approach should follow a stepwise algorithm starting with antipsychotic dose reduction or switching, followed by the addition of propranolol or benzodiazepines, with consideration of alternative agents for refractory cases.