Management of Antipsychotic-Induced Akathisia
The first-line management of akathisia involves dose reduction of the antipsychotic (if clinically feasible), switching to quetiapine or olanzapine, or adding propranolol 10-30 mg two to three times daily. 1, 2
Initial Assessment and Recognition
Before initiating treatment, recognize that akathisia can be misdiagnosed as psychotic agitation or anxiety, which may lead to inappropriate antipsychotic dose increases that worsen the condition. 2 The syndrome consists of both subjective restlessness (inner urge to move) and objective motor manifestations (pacing, rocking, leg crossing/uncrossing, marching in place). 3
Treatment Algorithm
First-Line Interventions
Dose reduction is the preferred initial strategy if positive symptoms are adequately controlled—reduce the antipsychotic dose while remaining within the therapeutic range. 1, 4
Switching antipsychotics to agents with lower akathisia liability should be strongly considered. Specifically, switch to quetiapine or olanzapine, which have demonstrated lower rates of akathisia. 1, 2, 5 Avoid antipsychotic polypharmacy as this increases side effect burden. 2
Propranolol is the most consistently effective pharmacological treatment when dose reduction or switching is insufficient. Use 10-30 mg two to three times daily. 1, 2, 3, 6 This represents the strongest evidence-based adjunctive treatment. 3, 4
Second-Line Options
If propranolol fails or is contraindicated (asthma, bradycardia, orthostatic hypotension), benzodiazepines such as clonazepam provide symptomatic relief, particularly addressing the anxiety component of akathisia. 2, 7 This is a sensible next choice when beta-blockers are unsuccessful. 3
Third-Line Alternatives
Anticholinergic agents are notably less effective for akathisia compared to other extrapyramidal symptoms, despite being commonly prescribed. 2 They should not be first-line for akathisia specifically. 4
5-HT2A antagonists including low-dose mirtazapine (7.5-15 mg once daily), mianserin, or trazodone represent emerging options with accumulating evidence. 6, 5 Mirtazapine has demonstrated the most compelling evidence among this class. 6
Fourth-Line Options
Amantadine (a mild dopaminergic agent) can be tried when other interventions fail, though evidence is limited. 2, 3
Critical Safety Considerations
SSRI-induced akathisia (particularly with fluoxetine) is associated with increased suicidality. 1, 2 Systematically inquire about suicidal ideation before and after SSRI initiation, and be especially vigilant if akathisia develops during SSRI treatment. 1, 2
Children and adolescents are at higher risk for extrapyramidal side effects including akathisia compared to adults. 8, 2 Monitor this population carefully.
Monitoring
Regular assessment using validated scales (such as the Abnormal Involuntary Movement Scale at baseline and every 3-6 months) is necessary to track both efficacy and side effects. 8
Common Pitfalls
Do not increase antipsychotic doses when akathisia is mistaken for worsening psychosis or anxiety—this worsens the condition. 2 Avoid relying on anticholinergics as first-line treatment for akathisia, as they are less effective than for other extrapyramidal symptoms. 2, 4 Do not continue antipsychotic polypharmacy when akathisia develops. 2