Q:  1) Do Most Antipsychotics Work as Effectively after Going Off Them and then Later Back on Them?  2) Can Atypical Antipsychotics Trigger Manic Episodes?
     
Dear Dr. Phelps,

Thank you for this wonderful forum whereby we can "bombard" you with our concerns/problems and you are unfailingly wise and discerning in your answers. 

Question:  Do most atypical antipsychotics (i.e. Risperdal) work as effectively if you have been taking it daily for two years, then stop taking it for a period of time (say a year), then find you need it again?  I know that lithium often does not work as well (or sometimes not at all) if you stop taking it, then try to resume the same dose.  

Another question:  Do you believe an atypical antipsychotic can trigger manic episodes?  My 20-year old daughter is one of the few who continually experienced "manic" breakthroughs when she took Lamictal at higher dosage (it made her anxious, irritable).  Lowering her dose really helped that problem. 

By the way, she is also on Lithium, which we know is her greatest defense against cycling.  I still think it is the "gold standard" among mood stabilizers!  Thank
you!


Dear Ms. M’ --
1.  Do antipsychotics like risperidone work as well the second time as they did the first time, if they are stopped for a while?  Answer: sometimes yes, sometimes no.  Most of the time, yes, actually.  But unfortunately, it seems that what we are treating can sometimes evil into a more treatment-resistant illness when the symptoms are not fully controlled.  Indeed, that is the current working model of treatment: get symptoms completely controlled and keep it that way, and there is a chance that you might prevent the progression of the illness.

In some people, however, the illness does not seem to progress when untreated.  Or maybe it is just going so slowly that we cannot really recognize the progression.  Either way, in those people, a gap in treatment is not such an unfortunate event.  However, at present we have no way of determining who is at risk of progression, so the current approach is to treat everyone to complete remission.

Of course, after many months or even a few years on a medication that is working perfectly, many people think "why am I still taking this stuff?  How do I know if I still need it?" I tell my patients to expect this thought and that when it arrives, they should come and see me before they change anything.  This way I at least get a look at exactly where we are before they start tapering the medication.  This is the opportunity to explain that there is a risk, just as you're asking here, that if they go off something, when they try to go back on that later, it may not work as well, or at all.  If they are still determined to go off the medication, which in some respects would be understandable if earlier symptoms had been relatively mild or if it has been a long time since they had any symptoms at all, I can give them explicit instructions on how to do so.

With lithium, it seems that tapering the medication off very slowly, over six months or more, is less likely to lead directly to relapse, then a sudden discontinuation. So if people are clearly determined to have a go at tapering off their medication, I always do this very slowly.  That way, if symptoms are going to return, they are less likely to come back suddenly (although this is not a guarantee); they may show up gradually enough that jumping back onto the medication gets things under control quickly -- if things go well.  Unfortunately, sometimes they do not go well.

2.  Can an atypical antipsychotic trigger a manic episode?  The answer is clearly yes.  My working hunch (based just on experience; there are no comparative data on this) would list the common antipsychotics, in terms of their likelihood of inducing manic symptoms, as follows:

• Ziprasidone (Geodon)
• risperidone (formerly Risperdal, now generic)
• aripiprazole at low doses
• olanzapine and quetiapine very rarely

A discussion of this issue with references supporting the idea, and the above order, can be found on my webpage on atypical antipsychotics (see the fourth paragraph).

Lamotrigine (Lamictal) is not an antipsychotic. It is not exactly a "mood stabilizer" either, by some peoples' definition (originally it was an anti-seizure medication).  It clearly has anti-cycling properties in many people, and antidepressant properties.  But once in a while, it does seem to be capable of acting too much like an antidepressant, and actually induces manic symptoms.  An experienced colleague and I, comparing notes, both estimated independently that this happens to about one person in every 20 or 30 who takes the medication.  So that is not rare.  At first I used to just stop at one this happened, but more recently it seems that just turning a ghost town can produce a stable good result.  It sounds like dad might have been your daughter's experience as well.

Thank you for your good questions.  And for your endorsement of lithium, which, you are right, is an unsung hero in this business.

Dr. Phelps



Published November, 2008