Patient with bipolar disorder on quetiapine 400 mg at bedtime, aripiprazole 5 mg daily, and trazodone 50 mg for sleep remains unable to sleep; should propranolol 10 mg twice daily be added for suspected antipsychotic‑induced akathisia?

Assess for Akathisia Before Adding Propranolol

Before adding propranolol, you must first confirm that akathisia is actually present and contributing to the insomnia, as the current medication regimen itself may be causing or worsening sleep disturbance. The patient is on aripiprazole, which has significant akathisia risk, but adding propranolol without confirmed akathisia could paradoxically worsen the situation.

Critical Assessment Steps

Evaluate for True Akathisia

• Use a validated akathisia scale (such as the Barnes Akathisia Rating Scale) to objectively document both subjective restlessness and objective motor findings before initiating treatment 1, 2
• Look specifically for: inner restlessness, urge to move, rocking while sitting/standing, pacing, and inability to sit still 3, 2
• Distinguish akathisia from anxiety, agitation, or psychotic restlessness 2

Consider Medication-Induced Insomnia

• Aripiprazole itself commonly causes insomnia as a direct side effect, independent of akathisia 4
• The combination of quetiapine 400mg (which should be sedating) with trazodone 50mg failing to produce sleep suggests either inadequate dosing or a medication causing arousal 1, 4

Treatment Algorithm Based on Findings

If Akathisia IS Confirmed:

First-line approach: Reduce aripiprazole dose before adding propranolol 1, 5, 2

• The APA guidelines recommend dose reduction, switching antipsychotics, or cessation of polypharmacy as preferred initial strategies 1, 2
• Consider reducing aripiprazole from 5mg to 2.5mg daily 5

If dose reduction is not feasible:

• Propranolol 10mg BID is appropriate as a first-line adjuvant medication for confirmed akathisia 1, 6, 3, 2
• Lipophilic beta-blockers like propranolol show the most consistent efficacy for acute akathisia 3, 2
• Monitor for orthostatic hypotension and bradycardia 6
• Screen for contraindications including asthma and significant cardiovascular disease 6

Important caveat: Recent evidence suggests propranolol may paradoxically increase akathisia risk during aripiprazole treatment through CYP2D6 inhibition, raising aripiprazole levels 7. This makes dose reduction of aripiprazole even more critical as the primary strategy.

If Akathisia is NOT Confirmed:

Address the insomnia directly rather than adding propranolol:

1. Optimize current sleep medications first 1

   • Increase trazodone to 100-150mg at bedtime (current 50mg dose is subtherapeutic for insomnia) 1
   • Ensure quetiapine 400mg is taken on an empty stomach to maximize absorption 1

2. Consider aripiprazole timing and dosing 4

   • Move aripiprazole to morning administration if currently given at night, as it can be activating 4
   • Alternatively, reduce aripiprazole dose to 2.5mg if clinically stable 5, 2

3. Avoid adding propranolol without confirmed akathisia, as it will not address insomnia and adds unnecessary medication complexity and drug interaction risk 7

Key Contraindications and Warnings

• Do not use propranolol as a sleep aid - it treats akathisia, not insomnia directly 6, 3, 2
• Propranolol with aripiprazole may increase akathisia risk through metabolic interactions 7
• Antipsychotics (including quetiapine and aripiprazole) are not recommended as primary insomnia treatments due to metabolic side effects and weak evidence 1
• Anticholinergics should be avoided as first-line akathisia treatment in this context 1, 5