ReviewsSelective serotonin reuptake inhibitor-induced akathisia
Section snippets
Presentation
Akathisia is most often referred to as a feeling of inner restlessness, but many patients may be unable to describe this feeling unless asked directly.5 Instead, patients sometimes confuse it with feelings of anxiety or agitation. An author of the current report (Dr. Makela) had a patient describe this feeling as “an itch inside that I can't scratch.” In a case presented by Walker,6 the patient described feelings of “wanting to jump out of my skin.” Altshuler et al.7 described a patient who
Importance of recognition
Akathisia is not always easy to recognize. Many patients taking SSRIs have preexisting psychiatric disorders, and misinterpreting akathisia symptoms can occur easily. These symptoms may be mistaken for agitated depression, anxiety, withdrawal, bipolar disorder, worry, or even restless leg syndrome.1,3,8,11., 12., 13. Misdiagnosing akathisia as an underlying psychiatric disorder could lead to an increase in dosage of the offending agent or the addition of a new, unnecessary medication such as an
Etiology
Although speculation exists, akathisia may result from a deficiency of dopamine in the brain. Reports in the literature suggest that this deficiency is caused by serotonergic-induced inhibition of dopamine in the mesocorticolimbic pathway projecting from the ventral tegmental area (VTA) of the brain to the prefrontal cortex.3,5 Like serotonin, noradrenalin acts similarly to inhibit dopamine in the VTA.3 Therefore, drugs increasing the stimulation of serotonergic or noradrenergic receptors in
Diagnosis
The Barnes Akathisia Rating Scale (BARS)22 can be used to assess a patient with suspected akathisia. This scale, developed in 1989 by Thomas Barnes, measures the subjective and objective aspects of akathisia. For the objective portion, the evaluator rates the amount of movement the patient displays on a scale from 0 (normal) to 3 (inability to remain still). The subjective portion is divided into two parts, awareness of restlessness and distress related to restlessness, both of which are
Predisposing factors
Reports from the literature have suggested several risk factors for developing akathisia (Table 2). The use of multiple akathisia-inducing drugs, a sudden increase in SSRI dose, and a previous history of akathisia may predispose patients to developing akathisia with SSRIs. The half-life and anticholinergic properties of individual SSRIs also may affect the risk of developing akathisia. Patients with baseline anxiety or panic conditions or patients with previous brain trauma appear to have
Management
Several treatment options for akathisia exist (Table 4). As discussed below, adding a centrally acting beta-blocker such as propranolol appears to be the most frequently used therapy. Benzodiazepines and anticholinergic drugs serve as other treatment options. Another choice for treatment is to switch to an alternative antidepressant or to change to another SSRI. In some cases, akathisia may subside over time without treatment.
The addition of a beta-blocker to a patient's regimen is an excellent
Conclusion
Akathisia is not a benign adverse effect. The effect can be extremely egregious, and some reports have linked akathisia with suicidality. With the increasing use of medications from this drug class for a variety of indications, identification of predisposing factors, early recognition of akathisia, and proper management are imperative. Beta-blockers and benzodiazepines are well-established treatment options for akathisia.
Pharmacists can play an active role in recognizing akathisia by being
Assessment Questions
Instructions: The assessment test for this activity must be taken online; please see “CPE Processing” below for further instructions. There is only one correct answer to each question. This CPE will be available online at www.pharmacist.com no later than March 31, 2009.
- 1.
A.B. is a 54-year-old woman who comes to your pharmacy regularly. You sit down to talk with her and observe her crossing and uncrossing her legs excessively. It appears that she can't sit still. She claims that she doesn't feel
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Published concurrently in Pharmacy Today and the Journal of the American Pharmacists Association.