What is the treatment for akathisia (involuntary movement disorder) caused by antipsychotic medications?

Treatment of Antipsychotic-Induced Akathisia

For akathisia caused by antipsychotic medications, first lower the antipsychotic dose or switch to quetiapine or olanzapine, and if symptoms persist, add propranolol 10-30 mg two to three times daily as the most effective pharmacological treatment. 1, 2

Algorithmic Treatment Approach

Step 1: Dose Reduction or Medication Switch

• Lower the current antipsychotic dosage while remaining within the therapeutic range as the initial intervention 1
• If dose reduction is not feasible due to symptom control needs, switch to an antipsychotic with lower akathisia risk, specifically quetiapine or olanzapine 1, 2
• Avoid antipsychotic polypharmacy, which increases side effect burden 2

Step 2: Add Beta-Blocker (First-Line Pharmacological Treatment)

• Propranolol 10-30 mg two to three times daily is the most consistently effective pharmacological treatment for akathisia 1, 2, 3, 4
• Propranolol demonstrates superior efficacy compared to placebo with response rates of 30-43% versus 6.7% 4, 5
• Monitor for contraindications including asthma, bradycardia, and orthostatic hypotension 3

Step 3: Add Benzodiazepine (Second-Line)

• If beta-blockers fail or are contraindicated, add a benzodiazepine such as clonazepam or lorazepam 1, 2
• Benzodiazepines provide symptomatic relief and address the anxiety component of akathisia 2, 4
• This is particularly useful when subjective distress persists despite other interventions 4

Step 4: Alternative Pharmacological Options

• Low-dose mirtazapine (7.5-15 mg once daily) has demonstrated compelling evidence with a 53.8% response rate versus 7.7% for placebo 3, 5
• Mirtazapine may be superior to propranolol in tolerability and is especially useful in patients with comorbid depression or negative symptoms 5
• Consider gabapentin or pregabalin as voltage-gated calcium channel blockers for resistant cases 6
• Amantadine is a fourth-line option with limited evidence 2, 4

Critical Clinical Pitfalls

Misdiagnosis Risk

• Akathisia is frequently misinterpreted as psychotic agitation or anxiety, leading to inappropriate increases in antipsychotic dosage that worsen the condition 1, 2, 7
• Distinguish akathisia from restless legs syndrome and psychotic agitation through careful assessment of the subjective inner restlessness and characteristic pacing movements 7

Medication-Specific Considerations

• Anticholinergic agents are notably less effective for akathisia compared to other extrapyramidal side effects, despite being commonly prescribed 1, 2
• Even atypical antipsychotics with minimal extrapyramidal effects (clozapine, quetiapine, aripiprazole) can still induce akathisia 6, 7

Special Populations

• Children and adolescents are at higher risk for extrapyramidal side effects including akathisia and require careful monitoring 1, 2
• Maintain high clinical suspicion in patients with motor disabilities, drug-induced parkinsonism, or those under mechanical restraint 6

Evidence Quality Considerations

The most recent international guidelines from The Lancet Psychiatry (2025) and the American Psychiatric Association (2020) provide the strongest recommendations, with propranolol and dose reduction/medication switching forming the cornerstone of treatment 1. The evidence for mirtazapine has strengthened considerably in recent years, with controlled trials demonstrating efficacy comparable to or exceeding propranolol 3, 5. However, propranolol remains first-line due to longer clinical experience and guideline endorsement 1, 2.