Benztropine is a perfectly fine drug when it is treating something: we give it as a PRN for restlessness on an antipsychotic rather than on a schedule. Look hard at standing benztropine nobody has questioned, and do not single it out as poison while prescribing other anticholinergic drugs without a thought.
When we reach for it
When a patient has a history of akathisia, even on the less akathisia-prone antipsychotics, or is simply worried about it, give benztropine as a PRN: take this if you become restless.
“When patients have told me about history of akathisia, even from the less akathetic medications, or just if the patient is concerned about it, I will give some benztropine, for example, as a PRN. Take this if you become restless”
Choosing Antipsychotics in Schizophrenia: Side-Effects, Maximizing Efficacy, and Finding the Right Medication | Episode 17Feb 2025
Dosing
Start with 0.5 mg tablets, one or up to two at a time, and ask the patient to call if they need more than 1 mg a day. Dispense 30 or 60.
“I like to start with a half milligram dose, and I say take one or up to two at a time. Call me if you need more than one milligram of the day and I give 30 or 60, whatever I kind of feel like”
Choosing Antipsychotics in Schizophrenia: Side-Effects, Maximizing Efficacy, and Finding the Right Medication | Episode 17Feb 2025
Compared with others
For akathisia long term, we prefer propranolol twice a day, which can work from as little as 10 mg twice a day. If it is mild, restless-legs-like and only at night, nighttime gabapentin can be quite effective.
“Long term, I do prefer to put people on propranolol. twice a day. You can get effect from as little as 10 milligrams twice a day for akathisia. If the akathisia is more like a restless legs thing that's mild and only at night, gabapentin can be quite effective, nighttime gabapentin”
Choosing Antipsychotics in Schizophrenia: Side-Effects, Maximizing Efficacy, and Finding the Right Medication | Episode 17Feb 2025
Pitfalls and myths
Check for standing benztropine that nobody has questioned. On clozapine, for example, you would not expect EPS, so there may be no reason for it; tapering it off can make no noticeable difference and may spare future cognitive problems.
“With clozapine, you wouldn't expect EPS, so it didn't make a lot of sense for me why he would be on cogettin if he didn't overtly have some weird EPS. He never noticed any difference, and I think I saved him some cognitive problems in the future”
Choosing Antipsychotics in Schizophrenia: Side-Effects, Maximizing Efficacy, and Finding the Right Medication | Episode 17Feb 2025 All anticholinergics are potentially unhealthy, and we give tons of them without calling them poison. Benztropine is perfectly fine; the rule is simply not to give a medication people do not need.
“All anticholinergics are potentially unhealthy. We give tons of anticholinergics without calling them poison. Benztropine is perfectly fine. You just shouldn't give a medication that people don't need”
Choosing Antipsychotics in Schizophrenia: Side-Effects, Maximizing Efficacy, and Finding the Right Medication | Episode 17Feb 2025 The same doctors who say never prescribe benztropine will give olanzapine and quetiapine without blinking, and those are already anticholinergic.
“The same doctors who say never prescribe the Benzterpene are also the same ones who will not blink and give Zyprexa and Seroquel, which are themselves already anticholinergic”
Choosing Antipsychotics in Schizophrenia: Side-Effects, Maximizing Efficacy, and Finding the Right Medication | Episode 17Feb 2025
Pearls
100 mg of clozapine is roughly equal to 2 mg of benztropine in anticholinergic terms. That is worth knowing if you ever need to stop clozapine suddenly.
“100 milligrams of clozapine is actually equal to 2 milligrams of benztropine. And this can be helpful to know because if you ever need to stop the clozapine suddenly”
37:37Top 10 Things to Know About ClozapineDec 2025
From these episodes
Every point above is something said on the Psychofarm podcast, with the words as spoken and a link to the moment in the episode. It is education, not medical advice, and an episode reflects what we thought when we recorded it.