Akathisia continues to present a significant challenge in clinical practice. As a class, so-called atypical, or second-generation,
antipsychotics (SGAs) are the mainstay of treatment for
schizophrenia and are commonly used to treat
mood disorders. These medications have traditionally been distinguished from first-generation
antipsychotics by their lowered risk of extrapyramidal side effects (EPS) such as
dystonia,
dyskinesia,
akathisia, and pseudoparkinsonism. However, the occurrence of EPS, particularly
akathisia, has been demonstrated to some degree in all commercially available SGAs. This review examines the incidence of
akathisia in nine newer SGAs in patients with
schizophrenia,
bipolar disorder, and
major depressive disorder (MDD). We performed a search of PubMed, ClinicalTrials.gov, Cochrane Central Register, and Google Scholar, as well as manufacturer websites and product labeling for published and unpublished clinical trials, meta-analyses, and systematic reviews. Studies evaluating adult patients with
schizophrenia,
bipolar disorder, or MDD were eligible for inclusion. Data on treatment-emergent
akathisia rates were gathered from each study, and potential dose-response relationships were explored. A total of 177 studies were included in this review, comprising 58,069 patients across 414 treatment arms. Compared with placebo with a composite 3.7% incidence of
akathisia, individual SGAs produced
akathisia at total composite rates ranging from 2.9-13.0% across the included studies. High doses of an SGA were generally associated with an increased risk of
akathisia. Clinicians should consider the risk of
akathisia when choosing a treatment option and monitor for
akathisia in patients beginning
therapy with an SGA or following a dose increase of the SGA.