Restless Leg Syndrome's Impact on Patient Mental Wellness and Documentation Guidelines

Your mental health patients face a hidden challenge that affects far more individuals than most practitioners realize. Studies reveal that 25.4% of individuals with mental health conditions experience RLS symptoms [5]. Restless leg syndrome, also known as Willis-Ekbom disease, creates an overwhelming urge to move the legs. Patients describe uncomfortable sensations like tingling or burning [15].

The impact on mental wellness is profound. Patients with RLS show markedly poorer sleep quality, more severe depressive symptoms, and heightened anxiety compared to those without the condition [5].

RLS operates under ICD-10 code G25.81. The relationship between this neurological disorder and psychiatric symptoms works both ways and can be devastating. Epidemiological studies document a two-to-fourfold higher risk of depressive disorders in individuals with RLS than in healthy controls [15]. RLS patients experience notably higher levels of anxiety and depression [15]. One study uncovered concerning odds of moderate depression (OR=6.15) and severe depression (OR=56.54) compared to those without the syndrome [10].

Most troubling is RLS's association with suicidal ideation [5]. This connection highlights why proper identification and documentation of this condition matters urgently in psychiatric practice. The syndrome occurs in approximately 5 to 10 percent of adults and twice as frequently in women as in men [15]. Recognizing, documenting, and addressing this syndrome forms an essential part of quality mental healthcare.

Understanding G25.81: Clinical Definition and Diagnostic Criteria

Accurate diagnosis of restless legs syndrome requires understanding both its formal classification and clinical presentation. Proper identification forms the foundation for addressing its significant impact on mental health and sleep quality.

ICD-10 Code G25.81 and Its Clinical Relevance

G25.81 serves as the specific ICD-10-CM code for restless legs syndrome, classified under "Diseases of the nervous system" within the extrapyramidal and movement disorders category [11]. This billable diagnostic code became effective in the 2026 edition on October 1, 2025 [2]. Clinically, G25.81 covers both idiopathic and secondary forms of RLS, including cases secondary to pregnancy [8].

Documentation requires attention to detail. Your clinical notes must address all diagnostic criteria and identify possible secondary causes [8]. Proper application of this code matters for reimbursement and establishes the neural basis of symptoms that might be misinterpreted as anxiety or agitation in psychiatric settings.

IRLSSG Diagnostic Criteria for RLS

The International Restless Legs Syndrome Study Group (IRLSSG) established five essential criteria for RLS diagnosis. These criteria received updates in 2012 following a four-year review process to improve diagnostic accuracy [8]:

1. Urge to move: An irresistible urge to move the legs, usually accompanied by uncomfortable sensations described as creeping, crawling, burning, or aching [9].

2. Rest-induced symptoms: The urge and unpleasant sensations begin or worsen during periods of rest or inactivity such as lying down or sitting [10].

3. Movement relief: Symptoms are partially or totally relieved by movement such as walking or stretching, at least as long as the activity continues [10].

4. Circadian pattern: Symptoms worsen in the evening or at night, displaying a clear circadian rhythm [10].

5. Differential diagnosis: Symptoms cannot be solely attributed to another medical or behavioral condition [10].

Mental health practitioners need to differentiate RLS from akathisia since both can manifest as motor restlessness. Akathisia typically lacks the sensory component and circadian pattern characteristic of RLS.

Differentiating Primary vs Secondary RLS

Primary (idiopathic) RLS differs from secondary forms in etiology, clinical course, and treatment approach. Primary RLS often has a genetic component, with 25–75% of cases showing familial patterns [10]. These patients typically experience symptom onset before age 45 and show slower disease progression [10].

Secondary RLS emerges from underlying conditions or external factors, most commonly:

• Iron deficiency: Serum ferritin levels below 50 ng/mL can trigger or worsen RLS symptoms [7]

• Pregnancy: Affects up to 19% of pregnant women, though symptoms typically resolve postpartum [7]

• Medication-induced: Several psychiatric medications can precipitate RLS, including:

  • Tricyclic antidepressants

  • Selective serotonin reuptake inhibitors (SSRIs)

  • Lithium

  • Dopamine antagonists [7]

Secondary RLS tends to develop more rapidly and may completely resolve if the underlying condition is treated [10]. Unilateral RLS symptoms more commonly indicate secondary forms rather than primary RLS [10].

Complete evaluation requires serum ferritin, chemistry panels to rule out uremia and diabetes, and neurological examination focusing on peripheral nerve function [7]. Recognizing these distinctions enables you to identify potential treatment targets and establish more effective management strategies for your patients experiencing both RLS and mental health challenges.

Psychiatric Comorbidities Associated with RLS

Mental health conditions and restless legs syndrome create complex clinical presentations. These connections require careful assessment to develop treatment approaches that address both physical symptoms and psychological distress.

Associations of Anxiety and Depression with Restless Leg Syndrome

The connection between G25.81 and mood disorders is both strong and bidirectional. Nearly half of RLS patients—47.9%—experience depressive disorders, while 22.7% suffer from anxiety disorders [5]. This prevalence far exceeds rates in the general population. Epidemiological research confirms a two-to-fourfold increased risk of depressive disorders in RLS patients compared to healthy controls [15].

Severity patterns reveal particularly striking findings. Among RLS patients with depression, an astonishing 97% experienced severe depression [15]. Depression severity correlates positively with RLS symptom frequency—as RLS worsens, depressive conditions intensify accordingly [15].

While RLS typically precedes mood disorders in most cases, emerging evidence shows this relationship works in both directions. Patients with high levels of depressive symptoms face increased risk for developing restless legs symptoms. Conversely, decreasing depression levels associate with lower odds of developing RLS symptoms during follow-up [11].

Prevalence of Suicidal Ideation in RLS Patients

The most concerning aspect of RLS-psychiatric connections involves suicide risk. RLS patients face a 2.7-fold higher risk of suicide or self-harm compared to those without the condition, even when controlling for depression, insomnia, and other chronic conditions [2]. This elevated risk appears consistently across multiple studies.

Previous suicidal ideation occurs in 22.0% of RLS patients. Additionally, 36.7% report passive suicidal thoughts [8]. Treatment doesn't eliminate these concerns—10.1% still report passive suicidal ideation within a two-week period [8]. Among untreated RLS patients, 28% report suicidal thoughts, three times higher than control groups [9].

Impact of RLS on Quality of Life and Daily Functioning

RLS symptoms disrupt multiple aspects of daily life. Studies show 85% of RLS sufferers report symptom interference with at least one aspect of daily functioning [10]. The most commonly affected areas span mood influence (50.5%), energy levels (47.6%), and normal daily activities (40.1%) [10].

RLS patients demonstrate decreased health-related quality of life scores comparable to serious chronic conditions like type 2 diabetes, clinical depression, and osteoarthritis [10]. These individuals are 46% more likely to experience limitations in activities of daily living and 71% more likely to face instrumental activities of daily living limitations [11].

For mental health practitioners, recognizing these associations proves critical for proper assessment and treatment planning. The quality of life impact combined with high risk of severe depression and suicidal ideation makes RLS a condition requiring careful attention in psychiatric practice.

Sleep Disruption and Its Role in Mental Health Decline

Sleep complaints affect 80.45% of RLS patients. These include delayed sleep onset, repeated awakenings, and non-refreshing sleep [3]. For patients with restless legs syndrome, sleep disruption creates a direct pathway to mental health deterioration.

Sleep Quality Assessment using PSQI in RLS Patients

The Pittsburgh Sleep Quality Index (PSQI) measures sleep disturbances effectively. Scores above 5 indicate poor sleep quality. Research shows that 78.2% of RLS patients qualify as poor sleepers [3].

The PSQI evaluates seven key components:

• Sleep duration

• Sleep disturbance

• Sleep latency

• Daytime dysfunction

• Habitual sleep efficiency

• Sleep quality

• Use of sleep medications

Global scores range from 0-21. Higher scores reflect worse sleep quality. Mean PSQI scores reach 7.9 in RLS populations, compared to 3.7 in control groups [12]. Sleep quality deterioration correlates directly with increasing RLS severity [3].

Daytime Sleepiness and Fatigue: ESS Score Analysis

Nighttime disruptions create daytime consequences. The Epworth Sleepiness Scale (ESS) measures excessive sleepiness through eight questions about dozing likelihood in everyday situations.

Research reveals 56.39% of RLS patients experience excessive daytime sleepiness [3]. Additionally, 31.7% score above the pathological threshold of 10 on the ESS [12].

Workplace impact is significant. Cross-sectional analysis identified reported restless legs as the strongest predictor of work performance problems (5.9%) [13]. This outweighs other factors including sleep apnea severity. RLS symptoms correlate more strongly with daytime sleepiness (7.6% of variance) than objective sleep apnea measures [13].

Insomnia as a Mediator Between RLS and Depression

Evidence supports insomnia as a key mediator between RLS and depression. Multivariate analyses show poor sleep efficiency as the strongest mediator of depression in RLS. This factor reduces the association between RLS severity and depression by more than 10% [14]. No other clinical factor studied exceeds this mediating effect.

Three insomnia manifestations correlate significantly with severe depression in RLS patients:

• Difficulty falling asleep (OR=8.16)

• Broken sleep (OR=11.66)

• Early morning awakening (OR=8.5) [15]

Human genetic evidence supports a potentially independent causal effect of insomnia on suicidal behavior [16].

Sleep disruption demands attention. RLS severity increases correspond with deteriorating sleep quality and quality of life [3]. This creates a destructive cycle: RLS disrupts sleep, poor sleep worsens mental health, and psychological distress potentially amplifies RLS symptom perception.

Medication-Induced RLS and Diagnostic Confusion

Several commonly prescribed psychiatric medications can trigger or exacerbate restless legs syndrome. This creates diagnostic challenges that directly affect treatment outcomes. Recognizing these medication effects becomes critical for proper symptom management and documentation.

SSRIs and Antipsychotics as RLS Triggers

Antidepressants pose a notable risk for RLS development. Selective serotonin reuptake inhibitors (SSRIs) like fluoxetine, paroxetine, and sertraline show consistent links to RLS symptoms [4]. Mirtazapine shows the highest risk, affecting 28% of patients with new-onset or worsening RLS symptoms [17]. Serotonin-norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine and duloxetine trigger RLS at rates between 2-10% [17].

Antipsychotic medications present an even greater concern. Olanzapine, quetiapine, and clozapine emerge as the most common RLS-inducing agents [18]. The prevalence of antipsychotic-induced RLS reaches 18.2% in clinical populations—substantially higher than the 5-10% observed in general population studies [19]. This effect contradicts current understanding of RLS mechanisms, given quetiapine's relatively low D2 receptor affinity compared to other antipsychotics [20].

Differentiating Akathisia from RLS in Psychiatric Settings

Distinguishing between medication-induced RLS and akathisia represents a critical diagnostic challenge. Akathisia manifests as generalized inner restlessness affecting the entire body rather than being localized to the legs [1]. RLS features distinctive "creepy-crawly" paresthesias that rarely occur in akathisia [1]. [RLS symptoms follow a circadian pattern](https://www.psychiatry-psychopharmacology.com/Content/files/sayilar/7/26_2_9(1), worsening at night, whereas akathisia lacks this temporal variation [19].

Movement patterns provide another key distinction. RLS movement temporarily relieves the uncomfortable sensation, with symptoms immediately returning when movement stops [1]. Akathisia involves movements like rocking or foot-shifting to relieve internal tension without the characteristic symptom-relief pattern of RLS [21].

Mood Stabilizers and Antiemetics: Overlooked Contributors

Other medication classes deserve attention as potential RLS triggers. Lithium appears in multiple case reports as an RLS inducer [4]. Antiemetics with dopamine-blocking properties—specifically metoclopramide and prochlorperazine—are frequently overlooked contributors [4].

Antihistamines operating on H1 receptors similarly contribute to RLS risk [4]. This connection becomes particularly relevant considering quetiapine's strong antihistaminic properties, which might partially explain its high association with RLS despite lower dopaminergic blockade [22].

Identifying medication-induced RLS presents additional complications since psychiatric patients have inherently higher baseline risk for primary RLS [18]. Careful documentation of medication timing, dosage, and symptom patterns becomes essential for accurate differential diagnosis.

Best Practices for Documentation and Referral

Effective documentation and appropriate referral timing make the difference between successful RLS management and missed opportunities in mental health settings. Your clinical approach to recording symptoms and connecting patients with specialists directly impacts treatment outcomes.

Documentation Essentials for RLS in Mental Health Records

Your documentation starts with recognizing how RLS presents across different patients [6]. Clinical notes need specific elements:

• All five diagnostic criteria from the International RLS Study Group

• Assessment of iron status through hemoglobin, transferrin saturation and serum ferritin [6]

• Medication review focusing on psychiatric medications that may trigger or worsen RLS

• Clear rating of symptom severity and sleep quality impact

Clinical Observation and Patient Communication

Patient validation matters significantly in RLS treatment [7]. Most RLS patients in psychiatric settings remain undiagnosed or unaware of their condition [23]. Active screening becomes your responsibility.

Document leg movement observations during clinical visits. These observations provide diagnostic clues that support your assessment and treatment planning.

Specialist Referral Guidelines

Certain situations require prompt specialist referral:

• Insufficient response to adequate initial treatment [6]

• Augmentation development (worsening symptoms despite increased medication) [6]

• Treatment ineffectiveness despite maximum recommended dosage [6]

• Intolerable medication side effects [6]

• Suspected RLS in children [6]

Primary Care Partnership in RLS Management

Primary care physicians handle most RLS cases effectively [7]. Specialist referral becomes necessary only when diagnosis remains uncertain or treatment fails [24]. Regular follow-up—initially at least every 3 months and annually for stable patients—ensures optimal outcomes [25].

Your role includes coordinating care between specialties while maintaining focus on the mental health aspects of RLS management.

Conclusion

Restless leg syndrome stands as a critical yet frequently missed element affecting your patients' mental health outcomes. This article has explored how G25.81 impacts adults across psychiatric settings, with particular attention to those already managing mental health conditions. The connection between RLS and psychiatric disorders creates clinical complexities that require both recognition and precise documentation.

Sleep disruption serves as the bridge connecting RLS to worsening psychiatric symptoms. Patients experiencing nighttime leg restlessness see their sleep quality decline, which directly intensifies anxiety and depression. This cycle helps explain the elevated rates of severe depression and suicide risk among RLS patients.

Medication awareness becomes crucial for effective patient care. Common psychiatric medications can trigger or worsen RLS symptoms, making careful review of SSRIs, antipsychotics, and mood stabilizers essential. Distinguishing RLS from akathisia remains a vital diagnostic skill that influences treatment success.

Documentation excellence requires capturing all five IRLSSG diagnostic criteria alongside potential secondary causes. This approach supports both billing accuracy and clinical decision-making. Knowing when specialist referral benefits your patients ensures they receive appropriate care when primary interventions prove insufficient.

The interconnection between physical symptoms and mental wellness cannot be ignored in psychiatric practice. Recognizing RLS's impact on sleep, mood, and suicide risk enhances your ability to provide thorough patient care. Your attention to this neurological condition improves both symptom management and overall quality of life for patients navigating mental health challenges.

Quality mental healthcare addresses the complete clinical picture, ensuring patients receive support for both neurological symptoms and psychological well-being.

Key Takeaways

Understanding the connection between restless leg syndrome and mental health is crucial for comprehensive psychiatric care, as this neurological condition significantly impacts patient wellness and requires specific documentation practices.

• RLS dramatically increases mental health risks: Patients face 2-4x higher depression rates and 2.7x increased suicide risk compared to those without the condition.

• Sleep disruption mediates RLS-depression connection: Poor sleep quality serves as the primary pathway linking restless legs to worsening psychiatric symptoms.

• Common psychiatric medications trigger RLS: SSRIs, antipsychotics, and mood stabilizers can cause or worsen symptoms, requiring careful medication review.

• Proper documentation requires all five IRLSSG criteria: Include urge to move, rest-induced symptoms, movement relief, circadian pattern, and differential diagnosis for accurate coding.

• Early specialist referral improves outcomes: Refer to neurology when treatment fails, augmentation occurs, or side effects become intolerable.

Recognizing RLS as both a neurological condition and mental health factor enables more effective treatment strategies that address the complete clinical picture rather than isolated symptoms.

FAQs

How does restless leg syndrome affect mental health?

Restless leg syndrome can significantly impact mental health. Patients with RLS are more likely to experience anxiety, depression, and cognitive difficulties. Studies show that individuals with RLS have a 2-4 times higher risk of developing depressive disorders compared to those without the condition.

What are the key diagnostic criteria for restless leg syndrome?

The essential diagnostic criteria for restless leg syndrome include an urge to move the legs, symptoms that begin or worsen during rest, relief by movement, worsening of symptoms in the evening or at night, and the absence of another medical condition that could explain the symptoms.

Can psychiatric medications trigger or worsen restless leg syndrome?

Yes, several psychiatric medications can trigger or exacerbate restless leg syndrome. Common culprits include SSRIs (selective serotonin reuptake inhibitors), certain antipsychotics, and mood stabilizers. It's important for healthcare providers to review medications when assessing RLS symptoms.

How does restless leg syndrome affect sleep quality?

Restless leg syndrome significantly disrupts sleep quality. Many patients experience difficulty falling asleep, frequent awakenings, and non-refreshing sleep. Poor sleep quality associated with RLS can lead to daytime sleepiness, fatigue, and further deterioration of mental health.

When should a patient with restless leg syndrome be referred to a specialist?

Referral to a specialist, such as a neurologist or movement disorder specialist, is recommended when initial treatment is ineffective, symptoms worsen despite increased medication (augmentation), maximum recommended dosage becomes ineffective, or when medication side effects are intolerable. Children with suspected RLS should also be referred to a specialist.

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