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Gabapentin for Neuroleptic-Induced Akathisia: A Report
In Session With Maria A. Sullivan, MD:
Gabapentin for Neuroleptic-Induced Akathisia: A Report
Maria A. Sullivan, MD, PhD
Associate Professor of Psychiatry, Columbia University Medical Center, New York, NY
Robert Wilbur, BS
Director, Robert Wilbur Associates, New York, NY
First published in Psychiatry Weekly, Volume 9, Issue
9, on June 23, 2014
Q: Gabapentin may not be the obvious choice to many clinicians when treating neuroleptic-induced akathisia. How did you embark on this experiment?
A: It began serendipitously when one of Dr. Sullivan’s private patients forgot to take his 1200 mg/nightly dose of gabapentin while receiving concurrent treatment with quetiapine, and the patient subsequently experienced a dramatic worsening of akathisia that did not abate until he took gabapentin.
In investigating this further, we found only one study on gabapentin for antipsychotic-induced akathisia.1 Also, the FDA had recently approved a long-acting formulation of gabapentin for restless legs, but it is very important to emphasize that neuroleptic-induced akathisia is much more severe than the neurological syndrome of restless legs and that the two should not be viewed or treated identically. Dr. Sullivan decided to ask the patient if he would participate in a small clinical investigation, in which gabapentin would be stopped periodically in order to objectively assess the effects on akathisia symptoms.2 The patient agreed and gave informed consent.
The second patient, also from Dr. Sullivan’s private practice, chose not to suspend gabapentin intentionally. However, we include a case report of her experience when she subsequently forgot her nightly dose of gabapentin.
Q: How did gabapentin affect neuroleptic-induced akathisia symptoms in these patients?
A: Patient 1 was male, 64 years old, with a lifetime history of GAD, panic disorder with agoraphobia, severe insomnia, and features of sub-clinical bipolar disorder, marked by irritability and a paradoxical response to antidepressants in which depression worsened. He received timolol maleate 20 mg tid, diazepam 10 mg tid and 20 mg hs, gabapentin 1200 mg tid, and quetiapine 100 mg tid and 200 mg hs. On the three occasions, spaced one week apart, when systematically omitting his nighttime dose of gabapentin 1200 mg from his nighttime dose of quetiapine, he went from experiencing no akathisia to experiencing severe akathisia (from 0 to 3 on the Barnes scale). Finding the akathisia intolerable, the patient took gabapentin 1200 mg on these “off” nights after 30 minutes of severe akathisia symptoms, which delivered complete relief.
Patient 2 was female, 58 years old with lifetime GAD, and bipolar depression with occasional hypomanic episodes. She received lithium carbonate 900 mg hs, quetiapine 100/400 mg hs, and gabapentin 600 mg/1200 mg. During periods of worsening of anxiety, she takes timolol maleate 10 mg bid, diazepam 10 mg prn (not to exceed 2 tablets daily) and clonazepam 1–2 mg hs prn. On one occasion when she forgot to take her nightly dose of gabapentin, she also experienced sudden, severe akathisia (from 0 to 3 on the Barnes scale) and intense anxiety. Her akathisia symptoms abated approximately 30 minutes after taking gabapentin.
Both patients required a beta blocker, timolol maleate, as well as benzodiazpines, because they both had prominent autonomic symptoms when they became anxious. During Dr. Sullivan’s observation of these two patients, however, only gabapentin appeared to be effective in relieving the patients’ neuroleptic-induced akathisia symptoms.
Disclosure: Dr. Sullivan and Mr. Wilbur report no affiliations with, or financial interests in, any organization that may present a conflict of interest.
References:
1. Pfeffer G, Chouinard G, Margolese HC. Gabapentin in the treatment of antipsychotic-induced akathisia in schizophrenia. Int Clin Psychopharmacol. 2005;20:179-81.
2. Sullivan MA, Wilbur R. Gabapentin pharmacotherapy for antipsychotic-induced akathisia: single-patient experiment and case report. Ther Adv Psychopharmacol. 2014;4:100-2.