Sudden Akathisia After a Ziprasidone Dose Reduction

Ms. A was a 27-year-old woman receiving carbamazepine. Because of a mixed episode, 120 mg b.i.d. of ziprasidone was added. After 2 months, ziprasidone was tapered to 80 mg b.i.d., and akathisia developed, with a Barnes rating scale score of 6. Ziprasidone was accordingly discontinued, and 40 mg b.i.d. of propranolol, 20 mg b.i.d. of diazepam, and 4 mg b.i.d. of biperiden were added to her treatment regimen.

Ms. B, who had been receiving 200 mg b.i.d. of lamotrigine when psychotic symptoms appeared, was also 27 years old. She did not respond to 3 weeks of ziprasidone, 120 mg b.i.d., and during the tapering process, a sudden and severe akathisia developed, with a Barnes rating scale score of 14. Ziprasidone was discontinued, and the already-mentioned protocol for the treatment of akathisia was applied.

Ms. C, a 46-year-old woman had her last manic episode treated with ziprasidone, 160 mg/day. After 4 weeks, her mania disappeared, but depressive symptoms emerged. Decreasing her ziprasidone dose to 120 mg/day was followed by abrupt akathisia, with a Barnes rating scale score of 9. Forty mg b.i.d. of propranolol, 30 mg b.i.d. of diazepam, and 4 mg b.i.d. of biperiden were added to her drug regimen for akathisia.

A rapid-cycling bipolar patient, Ms. D, age 61, was the eldest of our five cases. She had been given valproate and ziprasidone until she complained about sedation. Her ziprasidone dose was reduced to 120 mg/day from 160 mg/day, which was also followed by sudden akathisia with a Barnes rating scale score of 14 that responded only to clonazepam, 6 mg/day.

Ms. E, who had responded well to lithium prophylaxis but discontinued it because of polyuria, polydipsia, and urinary incontinence, was 48 years old. She refused to take valproate and olanzapine because she experienced hair loss and weight gain. Finally, she agreed to take 40 mg/day of ziprasidone for prophylaxis. But because of the appearance of depressive symptoms, it was also discontinued. This resulted in sudden akathisia with a score on the Barnes rating scale of 12. Her akathisia disappeared totally after treatment with 40 mg/day of propranolol, 4 mg/day of biperiden, and 2 mg/day of alprazolam. Although unexpected, akathisia after ziprasidone dose reduction in our cases was not persistent. Gradual or complete resolution of akathisia with 75% to 100% reduction in Barnes rating scale scores was observed within 7–10 days in all cases.