A 52-year-old woman is started on an SSRI for major depression. After 3 weeks she develops restlessness, inability to sit still, pacing, and distress but no muscle rigidity or fever. CK is normal. What is the most likely diagnosis and recommended management?

• A NMS; stop SSRI and start bromocriptine
• B Serotonin syndrome; stop SSRI and start cyproheptadine
• C Tardive dyskinesia; switch to a different antidepressant class
• D Akathisia; reduce SSRI dose or add propranolol/mirtazapine ✓

Explanation

Akathisia is a subjective feeling of inner restlessness with compulsive motor activity (pacing, rocking). It can occur with SSRIs (not just antipsychotics) and is a major cause of antidepressant non-adherence and worsening suicidality. Management includes dose reduction, switching agent, or adding propranolol (most evidence), low-dose mirtazapine (5-HT2 antagonist), or benzodiazepines. NMS requires rigidity and fever. Serotonin syndrome would show hyperreflexia and clonus. Tardive dyskinesia occurs with prolonged antipsychotic use.

Reference: Kaplan & Sadock's Synopsis of Psychiatry, 11th ed.

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