Does electroconvulsive therapy (ECT) help treat akathisia?

ECT for Akathisia: Not a Standard Treatment, But May Help in Rare, Severe Cases

ECT is not an established or guideline-recommended treatment for akathisia, but case reports suggest it may provide benefit in treatment-resistant tardive akathisia, particularly when accompanied by severe depression. 1, 2

Standard Treatment Approach for Akathisia

The evidence-based pharmacological management of akathisia follows the "B-CALM" approach, which should be exhausted before considering ECT:

• Beta-blockers (especially propranolol) are the most consistently effective first-line treatment for acute akathisia 3, 4, 5
• Clonazepam and other benzodiazepines are reasonable second-line options, particularly for subjective distress 4, 5
• Anticholinergics may provide some benefit, though evidence is less robust 3
• cLonidine can be tried if beta-blockers and benzodiazepines fail 4, 5
• Mirtazapine (low-dose) has strong evidence as an effective treatment option 3, 5

Additional agents with some evidence include gabapentin, pregabalin, and amantadine, though current data remains insufficient 3, 5

When ECT Might Be Considered

ECT is not mentioned in any akathisia treatment guidelines reviewed. However, isolated case reports describe success in highly specific circumstances:

• Treatment-resistant tardive akathisia that persists after withdrawal of the causative agent and fails all standard pharmacological interventions 1, 2
• Concurrent severe depression requiring ECT treatment, where akathisia improved as a secondary benefit 1, 2
• Extreme distress and suicidality related to refractory akathisia symptoms 1

One case report documented complete remission of both tardive akathisia and severe depression after ECT when all standard akathisia medications had failed 1. Another case from 1993 showed improvement in neuroleptic-induced akathisia resistant to traditional drug therapy 2.

Critical Caveats

• No controlled studies exist examining ECT specifically for akathisia treatment 1, 2
• Guidelines for drug-induced tardive akathisia management are non-existent, making this an area without established protocols 1
• ECT carries its own risks including memory impairment, prolonged seizures, and anesthesia-related complications 6, 7
• The mechanism by which ECT might improve akathisia is unknown and may be related to its effects on concurrent depression rather than direct action on akathisia 1

Practical Algorithm

1. First, optimize or discontinue the causative agent (reduce antipsychotic dose or switch to lower-risk second-generation antipsychotic) 3, 5
2. Trial propranolol or another lipophilic beta-blocker as first-line pharmacological treatment 3, 4, 5
3. Add benzodiazepines if beta-blockers provide insufficient relief 4
4. Consider mirtazapine (low-dose) as an alternative or adjunct 3, 5
5. Trial amantadine, clonidine, gabapentin, or pregabalin if initial treatments fail 4, 5
6. Consider ECT only if: akathisia is tardive (persisting after drug withdrawal), all standard treatments have failed, the patient has concurrent severe depression that would independently warrant ECT, and the patient is experiencing extreme distress or suicidality 1, 2

In real-world practice, ECT for akathisia alone would be considered experimental and should only be pursued after exhaustive trials of established treatments and in consultation with movement disorder specialists.