Akathisia From Antipsychotics: Inner Restlessness, Risk by Drug, and Treatment

Creator: Ryan S. Sultan, MD
Published: 2026-11-12

By Ryan S. Sultan, MD
Psychiatrist · Columbia University Irving Medical Center
Published November 12, 2026 · 6-minute read

Akathisia is a syndrome of motor restlessness seen mainly with antipsychotic medication. It combines a subjective sense of mental unease and an urge to move with particular patterns of restless movement.¹ In a pooled analysis of three randomized open-label trials in 493 people with first-episode psychosis, 19.5% had akathisia at 6 weeks, from 57% with haloperidol to 3.5% with quetiapine.²

New severe restlessness after an antipsychotic is started or the dose is raised should be reported to the prescriber promptly. Thoughts of self-harm call for emergency care right away.

What akathisia feels like, and how it differs from anxiety

A review describes two components. The subjective one is a feeling of inner restlessness and the urge to move. The objective one is movement: rocking while standing or sitting, lifting the feet as if marching on the spot, and crossing and uncrossing the legs while sitting.³

A 2018 guideline states that akathisia often goes unrecognized or is misdiagnosed as psychotic agitation, restless legs syndrome, anxiety, substance intoxication or withdrawal, or tardive dyskinesia.⁴ In a crossover trial of 12 patients, propranolol lowered both subjective and objective akathisia ratings without a significant change in anxiety scores.⁵

When akathisia starts and how long it lasts

Akathisia usually occurs during the early days of antipsychotic treatment, and naturalistic studies of psychiatric inpatients show it developing within hours or days of starting.⁴ In a four-week study of 73 inpatients starting antipsychotics, the incidence was 22.4%, 75% of cases occurred within the first three days, and dose increases in the first days of treatment had a significant influence.⁶ The cariprazine label tells prescribers to monitor for akathisia for several weeks after treatment begins and after each dose increase.⁹

Chronic akathisia is usually defined as signs and symptoms that continue for more than 3 months.⁴ A PubMed search for this page on November 12, 2026 found no figure for how long akathisia lasts after a dose is lowered or a drug is changed.

How often akathisia happens, by drug

The first-episode analysis found 57% with haloperidol, 20% with risperidone, 18.2% with aripiprazole, 17.2% with ziprasidone, 3.6% with olanzapine, and 3.5% with quetiapine.²

A meta-analysis of five newer agents in schizophrenia, bipolar disorder, and major depression trials, which did not include aripiprazole, estimated a mean incidence of 7.7%: 3.9% for iloperidone, 6.8% for asenapine, 10.0% for brexpiprazole, 12.7% for lurasidone, and 17.2% for cariprazine.⁷ In short-term schizophrenia trials on the labels, akathisia-related events occurred in 8% of patients on aripiprazole (Abilify) and 4% on placebo, and in 6-week trials akathisia occurred in 11% on cariprazine (Vraylar) and 4% on placebo.^{8, 9}

A network meta-analysis reported significant risk ratios for akathisia for 20 of 30 drugs, ranging from 1.95 for aripiprazole to 23.81 for zuclopenthixol.¹⁰ Because the other 10 drugs had no significant risk ratio, 1.95 is the lowest significant ratio and doesn't mark aripiprazole as the lowest-risk drug. A dose-response meta-analysis concluded that akathisia risk is dose-related and that sertindole and quetiapine carried negligible risk across the doses examined.¹¹

The evidence linking akathisia to suicidality is weak and mixed

A 1985 report described two cases of impulsive suicide attempts in which suicidal ideation appeared with akathisia and disappeared when the akathisia was treated.¹² A 2013 case report described a suicide attempt after a newly started antipsychotic produced intolerable akathisia.¹³
A study of 68 patients found akathisia associated with higher suicidality ratings, which the authors judged a nonspecific response to accompanying depressive mood.¹⁴
In an 8-week trial of 289 first-episode patients, suicidal ideation was associated with clinician-observed akathisia. The authors concluded that a promoting effect can't be ruled out.¹⁵ A single-case analysis of first-episode patients treated with haloperidol or risperidone found a positive relationship between suicidality and akathisia scores in a small subsample.¹⁶
A study in treatment-resistant schizophrenia (86 patients at first assessment) found no significant relationship at any time point.¹⁷
A nested case-control study of 84 people who died by suicide within 5 years of diagnosis found no statistically significant association between akathisia and suicide risk.¹⁸
An exploratory analysis of 109 patients found an association with suicidality in men but not in women.¹⁹

A 2001 review concluded that akathisia cannot unequivocally be linked to suicidal behavior, and the 2018 guideline calls the extent of the risk uncertain.^{20, 4}

The guideline's sequence: dose and drug first, then propranolol

The 2018 guideline recommends that clinicians consider reducing the antipsychotic dose, stopping antipsychotic polypharmacy, and switching to an antipsychotic with a lower perceived liability for akathisia before adding another medication. It gives clozapine, olanzapine, and quetiapine as examples of agents with a perceived lower liability for extrapyramidal side effects, and it asks clinicians to weigh dose reduction against the risk of clinical deterioration.⁴ These are the prescriber's decisions. Lowering or stopping an antipsychotic without the prescriber carries that same risk.

If an added medication is required, the guideline recommends considering propranolol as a first-choice option, with mirtazapine considered when propranolol is contraindicated, ineffective, or not tolerated and long-term treatment is anticipated. It advises against routine use of anticholinergics.⁴ A network meta-analysis of 19 trials with 661 participants found that no trials examined dose reduction or switching of antipsychotics.²¹

The treatment trials are small and short

The guideline counted 7 placebo-controlled propranolol trials with 194 participants, lasting 2 to 12 days. Six reported improvement.⁴ Three Cochrane reviews reached cautious conclusions:

Beta-blockers: three trials, 51 people, at most 72 hours. The review found insufficient data to recommend them.²²
Benzodiazepines: two trials, 27 people. They may reduce symptoms over a short follow-up.²³
Anticholinergics: no relevant randomized trials were identified.²⁴

In a 7-day trial of 90 patients, 43.3% responded to mirtazapine, 30.0% to propranolol, and 6.7% to placebo. Five of the 30 patients on propranolol stopped early because of low blood pressure or a slow heart rate.²⁵ In a 5-day trial of high-dose vitamin B6 in 20 inpatients, 8 of 10 had a reduction of at least 2 points on the global akathisia subscale, compared with 3 of 10 on placebo, and the result on the objective subscale was not significant.²⁶ The guideline warns that long-term high-dose vitamin B6 can cause a severe and progressive sensory neuropathy.⁴ Any add-on, including a supplement, is the prescriber's decision.

Limitations of the evidence

This evidence has limitations. First, incidence figures come from different populations, doses, and rating methods and can't be compared directly across studies. Second, the treatment trials lasted days, and a 2023 search found no trials of the guideline's first steps. Nevertheless, akathisia is common early in treatment and after dose increases, it's often mistaken for anxiety or agitation, and it warrants a prompt call to the prescriber.

Frequently asked questions

What does akathisia feel like, and how is it different from anxiety?

Akathisia is a feeling of inner restlessness with an urge to move, plus visible movements such as rocking, marching on the spot, and crossing and uncrossing the legs. A 2018 guideline notes it is often misdiagnosed as anxiety or agitation. New severe restlessness after starting or raising an antipsychotic should be reported to the prescriber promptly.^{3, 4}

Does Abilify cause akathisia?

In short-term schizophrenia trials on the label, akathisia-related events occurred in 8% of patients on aripiprazole and 4% on placebo. In a pooled analysis of 493 people with first-episode psychosis, 18.2% of those on aripiprazole had akathisia at 6 weeks.^{8, 2}

How common is akathisia with Vraylar?

In 6-week schizophrenia trials on the label, akathisia occurred in 11% of patients on cariprazine and 4% on placebo. A meta-analysis of five newer agents estimated 17.2% for cariprazine, the highest of the five.^{9, 7}

How long does akathisia last?

It usually begins in the early days of antipsychotic treatment, within hours or days of starting. Chronic akathisia is usually defined as signs and symptoms that continue for more than 3 months. Restlessness that persists is a reason to call the prescriber.⁴

Does propranolol help akathisia?

A 2018 guideline recommends considering propranolol as a first-choice option when an added medication is required, after the prescriber has considered the antipsychotic dose and drug. The evidence is 7 placebo-controlled trials with 194 participants lasting 2 to 12 days, and a Cochrane review found insufficient data to recommend beta-blockers.^{4, 22}

In a crisis: call or text 988, or go to the nearest emergency department. A first episode of psychosis belongs in a hospital-based or coordinated specialty care program.

I start and manage clozapine in an outpatient practice in Chelsea, Manhattan. Details are on the schizophrenia care in NYC page. Clozapine should not be stopped, skipped, or restarted without the prescriber. This page is general information and does not replace an evaluation.