MAGA — Make Akathisia Go Away; mere restlessness or unbearable torment?
Emergency Exit
In 1998, one Dr. Roger Lane, formely employed by Pfizer, wrote in the Journal of Psychopharmacology:
Akathisia can be so severe that death can be a welcome result.
The American Psychiatric Association, by contrast, portrays akathisia as merely “extreme restlessness characterized by an inability to sit or stand still and by fidgety movements or jitteriness, as well as a subjective report of inner restlessness.”
This hardly does justice to the intense suffering experienced by those stricken with it. A Canadian woman, whose name has been withheld, is enduring such mental torment that she attempted to end her life through Canada's controversial euthanasia program (though her request was denied by a B.C. Supreme Court judge who determined that akathisia was not an illness that would make her eligible.
That may change when Canada's Medical Assistance in Dying (known as MAiD) accepts “mental illness” as grounds to "legally" end a life. But is akathisia “all in the mind”? The judge who ruled that euthanizing the Alberta women with akathisia was unlawful appeared to consider akathisia curable, which contributed to his decision to block MAiD procedures. Is he right?
Expert advice must be followed
The case has gained prominence partly due to the time-scale, as the injunction barring euthanasia was granted just 24 hours before the scheduled death. There are many unknown factors, including how long the woman had suffered from akathisia before seeking MAiD, although it seems from the few details available that she has been enduring severe adverse effects from psychiatric drugs since 2018.
What is known is that she failed to gain approval for the procedure in her own region and instead approached Dr. Ellen Wiebe, a Vancouver-based physician, who signed off on the euthanasia after “meeting” with her over Zoom just once.
It was the woman’s husband who intervened to protest his wife’s impending death. He claimed that his wife had been told by two “experts” that akathisia was treatable, and that she was (in the language of his application):
... actively pursuing death, over the objections of the physicians who actively treat her.
No details on what treatment for akathisia was being offered to the woman are given.
'An inner sense of terror, all day long'
The woman, who had received a psychiatric diagnosis of “rapid cycling type 2 bipolar disorder,” was first prescribed medication to address her symptoms six years ago. One drug prescribed, quetiapine (brand name Seroquel, an antipsychotic) made her feel “drugged, extremely lethargic, and unable to move,” according to her husband. It also gave her an “inner sense of fear,” which is a hallmark characteristic of akathisia.
What followed was an attempt to taper off the Seroquel under medical direction (the standard advice for akathisia). It was a traumatic experience during which the woman described her side effects as “the horrors.” In the application for an injunction, the situation was presented in quite some detail:
As she was reducing her medication, [she] began describing distressing side-effects. She described having "the horrors" or an inner sense of terror all day long, the inability to sleep at night, nightmares, the inability to lie down during the day due to a feeling of falling, the inability to sit or remain still, suicidal thoughts.
At the same time, [she] continued to express her desire to die. She did not want to do it herself, and regularly begged [her partner] to end her life.
This situation apparently persisted for years with ups and downs along the way. Finally, in early 2024, the woman began investigating the possibility of euthanasia and found Dr. Wiebe online.
No easy way out — just 'manage' it...
Summarizing his reasons for agreeing to grant a 30-day injunction, Justice Simon Coval stated that euthanasia would clearly result in “extreme, irreparable harm.” While acknowledging the woman’s suffering and even admitting that his ruling would likely intensify it, he ruled against the legality of MAiD in her case:
I can only imagine the pain she has been experiencing and recognize that this injunction will only make things worse. But ... in my view, the interest of justice requires that this interim injunction be granted...
Particularly concerning is that akathisia appears to be a cluster of symptoms connected to the changes in usage of drugs used to treat a psychiatric condition. It is treatable but [the woman] has not followed treatment recommendations.
“Treatable,” of course, can mean many things. Notably, Justice Coval did not claim that akathisia is curable. Nor do leading psychiatrists make that claim. The medical literature describes “managing” the condition with various drugs, all of which have considerable side effects themselves. From the NIH (the U.S. National Institutes of Health):
Antipsychotic-induced akathisia may be managed by reducing the dose of the offending agent or switching to an alternative antipsychotic agent. Beta-blockers such as propranolol and benzodiazepines have historically been used for the treatment of akathisia although the amount of high-quality data supporting their use is limited.
Anticholinergic agents such as benztropine may be utilized if concomitant pseudoparkinsonism is present. Mirtazapine may also be utilized for the management of akathisia. Low-dose mirtazapine has been found to be as effective as beta-blockers and may be considered first-line therapy. However,one should use caution with this agent, because there are reports that high doses of mirtazapine may worsen akathisia.
... even if treatment causes more disease
The NIH urges caution in the use of all the abovementioned drugs, warning of possible dangerous side effects of lowered heart rate and low blood pressure:
When using beta-blockers, clinicians should be aware of the risk of bradycardia and hypotension.
Many other agents, including vitamin B6, have been used to treat akathisia, but there are no randomized controlled trials to determine their efficacy.
Trials investigating use of B6 and comparing it with propranolol have found that both have similarly low effectiveness. Naturally, B6 carries less risk of side effects, but it is no miracle cure.
What the NIH does not mention is that some of the drugs it recommends, specifically the benzodiazepines, can actually cause akathisia when the person withdraws from them.
Millions of victims, zero quality research
A Cochrane review of the medical literature on drug treatment of akathisia drew similar conclusions, noting that not a single clinical trial was of sufficient quality for its findings to be respected. This is quite a statement to make about research into a condition that is estimated to affect anywhere between 20 and 75 percent of people who take antipsychotics (as well as SSRI antidepressants):
Estimates of the prevalence of akathisia in neuroleptic‐treated people range between 20% and 75%, occurring more frequently in the first three months of treatment.
The first references in the medical literature to drug-related akathisia appeared in 1960, concerning patients who were taking phenothiazines (early antipsychotics). Akathisia was described by doctors then as “muscular restlessness,” and was viewed by some as the same “inability to sit” that physicians first described in 1901. The non-drug-related akathisia, however, is a very different animal to the iatrogenic variety.
There are several types of akathisia, categorized according to how and when the symptoms begin and how long they persist. Acute akathisia begins within days or weeks of starting or increasing the dose of a drug. Chronic akathisia begins later and persists for at least several months. Tardive akathisia begins either several months into drug treatment or after reducing or withdrawing from the drug.
Which drugs? In fact, not only psychiatric drugs are implicated in akathisia. Other commonly prescribed drugs have also been documented as causing this feeling of inner torment, such as antiemetics (drugs taken to counter nausea and vomiting); Accutane, a drug used to treat severe acne; azithromycin, a commonly prescribed antibiotic; and anti-epileptic drugs (also known as mood stabilizers) such as lithium carbonate.
Protecting psychiatry's reputation?
The DSM-5 (the most recent edition of the Diagnostic and Statistical Manual of Psychiatry) describes akathisia as "restlessness, fidgeting of the legs, rocking, pacing, and the inability to sit or stand still," and acknowledges the link between it and psychiatric drug use. While it omits the (possibly more significant) emotional symptoms, that would seem to strengthen the case for considering it a physical rather than a mental condition.
Why, then, has a Canadian judge refused to grant access to MAiD to a woman with a condition caused by the drugs prescribed to her by the Canadian medical establishment, when countless other Canadians suffering from other physical and non-fatal ailments are presented with that "easy" (and cost-effective) way out? One theory is that his wish to portray akathisia as a treatable condition may have overridden the desire to promote euthanasia as a simple solution to society’s ills.
What the judge did not suggest was that the woman’s desire to commit suicide was a direct result of being medicated — that she had no motive whatsoever, and simply felt compelled to kill herself. Suicidal ideation is a known side effect of many psychiatric drugs, but many dismiss its significance as “the underlying mental disorder reasserting itself" or simply fail to inquire into its meaning.
What if akathisia is the real culprit behind the numbers of suicides — and homicides — linked to psychiatric drugs? The second part of this article will address that question.
The information contained in this article is for educational and information purposes only and is not intended as health, medical, financial or legal advice. Always consult a physician, lawyer, or other qualified professional regarding any questions you may have about a medical condition, health objectives, or legal or financial issues.
If you are struggling with suicidal thoughts, you can call a qualified mental health helpline or seek help from a qualified therapist.
