67 - References

References

Bipolar disorder CHAPTER 2 Practice guide to tapering ■ ■Patients should be told that there is the possibility of withdrawal effects, and that there may be an increased risk of affective relapse from stopping lithium or mood stabilisers more quickly. These effects will be reduced if these medications are reduced in a more gradual fashion. ■ ■There is no clear evidence on how to taper (or for how long), but following principles from other psychotropic medications, an initial reduction of 10–­25% of the current dose should be offered, with withdrawal symptoms (Table 2.13) and symptoms monitored for at least 4 weeks to ensure stability. ■ ■Further reductions should be titrated against the tolerability of this dose decrease. Reductions should probably be made according to an exponentially reducing pattern, whereby each reduction is calculated as a fixed proportion (e.g. 10% or 25%) of the most recent dose (effectively becoming smaller and smaller as the total dose becomes lower) each month, or until stability is assured. ■ ■For a very few patients the final dose before completely stopping may be very small, because small doses have relatively large effects on target receptors. This may be as small as 1% of therapeutic doses, for example <10mg for lithium. To achieve small doses, liquid preparations (lithium) will be required. ■ ■As the process of reducing lithium or mood stabilisers might be destabilising it may be wise to pursue other strategies during the tapering period.20 Ongoing monitoring may be necessary for a number of months after complete cessation to ensure mood stability. ■ ■If withdrawal symptoms or symptoms of relapse emerge at any point, pausing the reduction, a small increase in dose or returning to a previously effective dose are all possible responses. Difficulty reducing medication does not preclude a further attempt at reduction but might indicate the need for a more gradual reduction regimen. ■ ■Other modalities for people with bipolar disorder, including family therapy, interpersonal therapy, cognitive behavioural therapy, psychoeducation and social rhythm therapy, may be considered as well as more individualised, idiosyncratic coping strategies.21–­23 References

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4. Baastrup PC, et al. Prophylactic lithium: double blind discontinuation in manic-­depressive and recurrent-­depressive disorders. Lancet 1970; 2:326–­330. Box 2.3  Suggested slow reduction regimen for lithium ■ ■Reduce by 200mg every month until dose is 800mg daily, then ■ ■Reduce by 100mg every month until dose is 400mg daily, then ■ ■Reduce by 50mg every month until dose is 100mg daily, then ■ ■Reduce by 25mg every month until completely stopped

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