Atypical Antipsychotics & Akathisia
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Q:  Atypical Antipsychotics & Akathisia


I've been in touch with you before about Lamictal and sexual dysfunction. I ended up having to discontinue the Lamictal because it was to activating/agitating (culminating in my first panic attack). But, I thought I'd let you know that once I discontinued the Lamictal, the sexual function did resolve without any other med changes.

I'm writing today to ask you a question about a side effect of the atypical antipsychotics (AAPs). My pdoc and I have been trying a few of these out to see if we can help for my dysthymia and anxiety without sending me into hypomania. (The main signal that I might be in the BP spectrum is an episode of antidepressant-induced hypomania).

The problem I've been having with the AAPs is akathisia: jitteriness/agitation, needing to be constantly moving my legs, irritability. And this is at low doses. Have you encountered this in your practice? If so, do you generally find that it tends to go away on its own?

Also, I understand that there are various medication-based approaches to managing akathisia. Because I would also like to quit smoking, my pdoc has prescibed Amantadine, which he believes should help with both the smoking and the akathisia. Do you have any thoughts about this approach?


Dear Henry -- 
Thanks for the update on those aspects of lamotrigine.  As for the jitteriness/agitation: I'll bet one of the AAP's you tried was aripiprazole (whose smarmy trade name Abilify ought to be avoided in print). As you probably know, it's famous for causing this -- and not representative of the rest of the atypicals in this respect. But you got a similar or identical side effect on another? The most likely of the rest to do that would have been risperidone, which at higher doses is also famous for this, though generally it does not cause it at lower doses (however, I just saw a patient yesterday who was feeling stiffness, a related side effect, on risperidone at one eighth of a mg, where typical doses are in the 2-6 mg range). 

If you got this jitteriness/agitation on quetiapine (Seroquel), that would be very unusual but not unheard of (I've seen it in a few patients, even though I did not use a lot of Seroquel until recently). As for olanzapine (Zyprexa), I'd be even more suprised to see it with that one.  That leaves Geodon, where side effects seem to me to be a grab-bag deal: you can get almost anything on Geodon, from sedation to agitation; in other words, it wouldn't be surprising there either. 

Thus, if you haven't had Seroquel yet, you could keep that one on the list. Your doctor may have avoided it thus far because of the higher risk of weight gain and glucose/cholesterol increases with that one than with aripiprazole and Geodon.  Those are risks all right but can be watched closely.  

As for amantadine, I've used it a few times because it was shown to potentially decrease the weight gain risks of Zyprexa. It did cause some weight loss, but several of the folks in whom I tried it had to stop because of, ironically for your question, agitation and tremor.  That's the limit of my experience with it; I'll bet your doctor knows something I don't there. 

Dr. Phelps

Published October, 2005


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