When a patient develops akathisia on a second‑generation antipsychotic, does it typically improve with time or require immediate discontinuation of the antipsychotic?

Akathisia Associated with Second-Generation Antipsychotics: Management Strategy

Akathisia from second-generation antipsychotics does not reliably improve with time and requires prompt intervention—either dose reduction, medication switching, or adjunctive treatment—rather than waiting for spontaneous resolution. 1

Why Immediate Action is Necessary

Akathisia is frequently misinterpreted as worsening psychosis or anxiety, leading clinicians to inappropriately increase antipsychotic doses, which paradoxically worsens the condition. 1 This misrecognition is particularly dangerous because:

• Akathisia is associated with increased suicidality, especially when induced by certain medications, and clinicians must systematically inquire about suicidal ideation when akathisia develops. 1
• The subjective distress from akathisia is a common reason for medication noncompliance, undermining treatment effectiveness. 2
• Even low, introductory doses of commonly used SGAs like aripiprazole and lurasidone can precipitate severe akathisia that requires immediate discontinuation. 3

First-Line Management Algorithm

Step 1: Reduce Antipsychotic Dose

• Lower the current antipsychotic dosage while remaining within therapeutic range as the initial intervention. 1
• This approach is preferred when the patient's psychiatric condition is stable enough to tolerate dose reduction. 4

Step 2: Switch Antipsychotic if Dose Reduction Fails

• Switch to an antipsychotic with lower akathisia risk, specifically quetiapine or olanzapine (with samidorphan combination or concurrent metformin to attenuate weight gain). 5, 1
• Perform gradual cross-titration informed by the half-life and receptor profile of each medication. 5
• Avoid antipsychotic polypharmacy, which increases side effect burden without improving akathisia. 1, 4

Step 3: Add Adjunctive Medication if Switching is Not Feasible

When dose reduction or switching is not clinically appropriate, add:

Primary option:

• Propranolol 10-30 mg two to three times daily is the most consistently effective treatment for akathisia. 1, 6, 2

Alternative options if propranolol is contraindicated:

• Mirtazapine at low doses (15 mg) has demonstrated substantial efficacy in severe, treatment-resistant akathisia. 6, 2, 7
• Clonazepam can provide symptomatic relief and address the anxiety component of akathisia. 1, 6

Important Caveats

What NOT to Do

• Do not use anticholinergic agents (e.g., benztropine) as first-line treatment—they are notably less effective for akathisia compared to other extrapyramidal side effects, despite being commonly prescribed. 1, 4
• Do not increase the antipsychotic dose when a patient appears more agitated, as this may represent akathisia rather than worsening psychosis. 1

Monitoring Requirements

• Document abnormal movements at baseline before starting antipsychotic therapy. 1
• Repeat assessments every 3-6 months using the Abnormal Involuntary Movement Scale (AIMS). 1
• Systematically assess for suicidal ideation, particularly if akathisia develops during treatment. 1

Special Populations

• Children and adolescents are at higher risk for extrapyramidal side effects including akathisia compared to adults. 1
• Up to 50% of youth on antipsychotic medication develop some form of movement disorder. 1

Prognosis

• Acute akathisia commonly resolves upon treatment discontinuation or with appropriate intervention. 2, 4
• However, tardive and chronic akathisia may persist after the causative agent is withdrawn and prove resistant to pharmacological treatment. 2
• Akathisia has a good prognosis when managed early in the course of treatment. 6

Duration of Adjunctive Treatment

If adjunctive medications are used, the need for these agents should be reevaluated after the acute phase, as many patients no longer require them during long-term therapy. 1 Limitations in the evidence warrant cautious prescribing, particularly regarding duration of use of adjuvant medications. 4