Barnes Akathisia Rating Scale (BARS)

Instructions

Patient should be observed while seated, and then standing while engaged in neutral conversation (for a minimum of two minutes in each position). Symptoms observed in other situations may also be rated. Subsequently, the subjective phenomena should be elicited by direct questioning.

Objective

0 - Normal: occasional fidgety movements of the limbs

1 - Presence of characteristic restless movements: shuffling or tramping movements of the legs/feet, or swinging of one leg while sitting, and/or rocking from foot to foot or "walking on the spot" when standing, but movements present for less than half the time observed

2 - Observed phenomena: as described in (1) above, which are present for at least half the observation period

3 - Constantly engaged: patient is constantly engaged in characteristic restless movements, and/or has the inability to remain seated or standing without walking or pacing, during the time observed

Subjective: Awareness of Restlessness

0 - Absence of inner restlessness

1 - Non-specific sense of inner restlessness

2 - Aware of inability: the patient is aware of an inability to keep the legs still, or a desire to move the legs, and/or complains of inner restlessness aggravated specifically by being required to stand still

3 - Intense compulsion: awareness of intense compulsion to move most of the time and/or reports strong desire to walk or pace most of the time

Subjective: Distress Related to Restlessness

0 - No distress

1 - Mild

2 - Moderate

3 - Severe

Global Clinical Assessment of Akathisia

0 - Absent: No evidence of awareness of restlessness. Observation of characteristic movements of akathisia in the absence of a subjective report of inner restlessness or compulsive desire to move the legs should be classified as pseudoakathisia

1 - Questionable: Non-specific inner tension and fidgety movements

2 - Mild akathisia: Awareness of restlessness in the legs and/or inner restlessness worse when required to stand still. Fidgety movements present, but characteristic restless movements of akathisia not necessarily observed. Condition causes little or no distress.

3 - Moderate akathisia: Awareness of restlessness as described for mild akathisia above, combined with characteristic restless movements such as rocking from foot to foot when standing. Patient finds the condition distressing

4 - Marked akathisia: Subjective experience of restlessness includes a compulsive desire to walk or pace. However, the patient is able to remain seated for at least five minutes. The condition is obviously distressing.

5 - Severe akathisia: The patient reports a strong compulsion to pace up and down most of the time. Unable to sit or lie down for more than a few minutes. Constant restlessness which is associated with intense distress and insomnia.

Evidence-Based Treatment Options for Antipsychotic-Induced Akathisia

Based on systematic review and network meta-analysis by Gerolymos et al. (JAMA Network Open, 2024)

First-Line Treatments (Highest Efficacy)

Vitamin B6 (Pyridoxine)

High Evidence

Dosing: 600-1200 mg/day for 5 days

SMD: -0.92 (95% CI: -1.57 to -0.26)

Mechanism: Dopamine balance correction, free radical scavenger

Advantages: Best risk-benefit ratio, excellent tolerability

Side Effects: Minimal to none at therapeutic doses

Clinical Pearl: May be first choice due to safety profile

Mirtazapine

High Evidence

Dosing: 15 mg/day for 5 days

SMD: -1.20 (95% CI: -1.83 to -0.58)

Mechanism: 5-HT2 antagonism

Advantages: Highest effect size, may help with comorbid depression

Side Effects: Sedation, weight gain

Clinical Pearl: Consider for patients with insomnia or depression

Biperiden

High Evidence

Dosing: 6-12 mg/day for 14 days (optimal: 12 mg/day)

SMD: -1.01 (95% CI: -1.69 to -0.34)

Mechanism: Anticholinergic activity

Advantages: Large effect size, available PO and IM

Side Effects: Sedation (48% of cases), anticholinergic effects

Clinical Pearl: Best alternative if vitamin B6 and mirtazapine fail

Second-Line Treatments (Moderate Efficacy)

Trazodone

Moderate Evidence

Dosing: 50-100 mg/day for 5 days

SMD: -0.84 (95% CI: -1.54 to -0.14)

Mechanism: 5-HT2 antagonism

Advantages: Significant efficacy

Side Effects: Drowsiness, rare priapism in men

Clinical Pearl: Avoid in men with hematologic/neurologic conditions

Mianserin

Moderate Evidence

Dosing: 15 mg/day for 5 days

SMD: -0.81 (95% CI: -1.44 to -0.19)

Mechanism: 5-HT2 antagonism

Advantages: Good tolerability profile

Side Effects: Sedation

Clinical Pearl: Similar to mirtazapine but less sedating

Propranolol

Moderate Evidence

Dosing: 20-50 mg/day for 6-8 days

SMD: -0.78 (95% CI: -1.35 to -0.22)

Mechanism: β1-adrenergic receptor blockade

Advantages: Well-established option

Side Effects: Hypotension, contraindicated in asthma/COPD

Clinical Pearl: Administer for >2 days for optimal efficacy

Not Recommended (Insufficient Evidence)

Limited Evidence Medications

Low Evidence

Cyproheptadine: Conflicting results, cannot be currently recommended

Clonazepam: No significant difference vs placebo

Valproate: No significant difference vs placebo

Zolmitriptan: Insufficient data

Recommended Treatment Algorithm

1st Choice: Vitamin B6 600-1200 mg/day × 5 days (best risk-benefit ratio)

2nd Choice: Mirtazapine 15 mg/day × 5 days (if depression/insomnia present)

3rd Choice: Biperiden 12 mg/day × 14 days (if above options fail)

Alternatives: Trazodone 100 mg/day, Mianserin 15 mg/day, or Propranolol 50 mg/day

Note: 10-20% of patients may not respond to serotonin-based treatments, suggesting other mechanisms may be involved.

References:

1. Barnes TR. A Rating Scale for Drug-Induced Akathisia. British Journal of Psychiatry 154:672-676, 1989.

2. Gerolymos C, Barazer R, Yon DK, et al. Drug Efficacy in the Treatment of Antipsychotic-Induced Akathisia: A Systematic Review and Network Meta-Analysis. JAMA Network Open. 2024;7(3):e241527.

Barnes Akathisia Rating Scale (BARS)

Instructions

Objective

Subjective: Awareness of Restlessness

Subjective: Distress Related to Restlessness

Global Clinical Assessment of Akathisia

BARS Assessment Results

Medical Note:

Evidence-Based Treatment Options for Antipsychotic-Induced Akathisia

First-Line Treatments (Highest Efficacy)

Vitamin B6 (Pyridoxine)

Mirtazapine

Biperiden

Second-Line Treatments (Moderate Efficacy)

Trazodone

Mianserin

Propranolol

Not Recommended (Insufficient Evidence)

Limited Evidence Medications

Recommended Treatment Algorithm