Hypomania with lamictal/lamotrigine withdrawal?
November 27, 2022 4:20 PM   Subscribe

Some questions about hypomanic symptoms during a lamotrigine taper, inside.

My SO is now tapering off lamotrigine. He was on 200 mg for a few years. He cut to 175 mg and it’s been just over two weeks. He is bouncing off the walls. Dancing, then irritable, then talking loudly, then getting upset… also sleeping less (currently at 6-8 hours a night, until recently was sleeping 10-16 hours a night, which of course wasn’t good either, anyway).

A read of social media suggests this is common, including in people who have never experienced hypomania before (eg people who were on it for epilepsy!). My question is, how long might this last? Would he normalize without further pharmacological assistance or reinstatement of his original dose with some time? Does he need a temporary medication to help him through this period? Currently he’s relying on indica and gabapentin which aren’t doing much. And occasionally loxapine at night.

Worth mentioning that he recently tried and stopped two SSRIs (see my recent question). He’s been on a medical magical mystery tour since the summer, it’s just been awful.

The psychiatrist he’s seeing originally had him set on a taper of -50 mg every two weeks, which evidently became impossible after two days (holy shit is all I have to say about those two days). So he’s reducing by 25 mg. The follow up is booked for early Jan at which time she expects him to be off it. I mean this is just not going to happen, or if he tries he’ll be hospitalized before then.

Online people recommend either a micro taper (tiny increments reduced daily), or only reducing by 5-10% a few weeks after withdrawal effects from the previous taper stabilize.
posted by cotton dress sock to Health & Fitness (12 answers total)
 
Response by poster: He also takes lithium, a statin and synthroid.
posted by cotton dress sock at 4:22 PM on November 27, 2022


Sorry to not answer your exact question, but I feel you need to find a different psychiatrist ASAP. This is from personal experience. Not my experience, but the experience of a very close friend. As you mention, the alternative is instant hospitalization. Don't wait. Actually I'd go with the hospital, for everyone's safety.
posted by mumimor at 5:14 PM on November 27, 2022 [2 favorites]


Not to abuse the edit window, but at the time when this happened, I was the only friend because the hypomania had gone beyond all boundaries, including my friend's wife's. Don't let this happen. Get help now.
posted by mumimor at 5:17 PM on November 27, 2022 [2 favorites]


This was not my experience at all with a lamotrigine taper. Take social media reports with a grain of salt.

6-8 hours of sleep is not bad at all, “bouncing off the walls” is. Consider medical intervention. Why is the doctor recommending lamotrigine withdrawal? A second opinion would be good.

If he must self-medicate, he should consider going up on lithium. Also avoid mixing meds as a recovery strategy as that makes it hard to identify the drug that is causing the troubling symptoms.
posted by shock muppet at 5:29 PM on November 27, 2022


See a pharmacist who can show you where the medication conflicts are. Get a new Psych or a Neurologist. This is way too many very powerful drugs.
posted by Oyéah at 6:17 PM on November 27, 2022


Response by poster: Hospitals where we are (Toronto) are in crisis (as is the whole system), they only do much for people with current suicidal or homicidal plans, and he would do anything to avoid one in any case, though I totally agree it might be a good idea in theory and also ****totally**** agree he needs a new psychiatrist. That unfortunately is also a hard thing to make happen in under a year if at all. He could contact his current psychiatrist (there’s no easy way but it’s possible, it’s through a hospital clinic). The concern would be she’d probably want to reinstate the med or even double down. It didn’t do anything for him at all (hence the SSRI trials) and we think it’s been contributing to some of his gastrointestinal problems…

Given a rediagnosis, the plan moved to getting him off the lamotrigine and the lithium (later). The gabapentin and loxapine (also long-standing prescriptions, predating this doctor) are PRN for emergencies (and have been necessary).

Social media reports, sure grain of salt, I mean we only went to that after he completely lost his shit trying the 50 mg taper. He has been on and tapered from multiple antipsychotics and has never experienced anything like this before. (The SSRIs were another kind of horrible trip).

Thanks everyone for your help and suggestions.
posted by cotton dress sock at 6:54 PM on November 27, 2022


Is CAMH an option? They might be able to advise you more expertly and the do have a 24/7 emergency.
posted by warriorqueen at 7:14 PM on November 27, 2022 [1 favorite]


Best answer: Well, I went through SSRI withdrawal in the past year and I found there is very limited information to be found on how long psych med withdrawal will last, beyond the fact that it varies a lot by individual. There doesn’t even seem to be data on how many people experience withdrawal symptoms. Doctors tend to be extremely uninformed about the issue, attribute everything to your underlying mental health condition, and only suggest reinstating the drug.

This isn’t the response that I want to give, but it is what I feel is the most truthful one. I am sorry you’re dealing with this and am not sure what is best for you to do now. But if he wishes to continue tapering off the drug once stabilized, I would strongly suggest following the micro tapering advice from the online forums.
posted by vanitas at 10:32 PM on November 27, 2022 [1 favorite]


Best answer: CAMH has a 24/7 Emergency Psychiatry Department, if you are seeking short-term access to psychiatric care. However, they may not be very helpful where there is an existing psychiatrist involved, and may not want to interfere in an existing management plan. They will want to know whether and how you've tried to get an appointment with the existing psychiatrist. That said, they might prescribe something to address the hypomania.

I would still first contact the hospital clinic through which he is seeing this psychiatrist and request an emergency visit on the basis that he is experiencing potentially dangerous unintended side effects of medication tapering. Knowing the Canadian healthcare system and at least how psychiatric care works in BC, I don't think you will be able to avoid this.

If you can't get a short term appointment with his psychiatrist, I would try the CAMH option.

You could also try a family doctor appointment in that event.

You can still seek out a different psychiatrist eventually, I would think via your family doctor sending out referrals to every possible option, but for now I don't think you can do better than the above.

There is no evidence that Lamotrigine treats or prevents hypomania. Expect that he might be prescribed an anti-psychotic or other drug to bring down the hypomania. I've never heard of this as a risk for Lamotrigine withdrawal (as someone who takes it), but everyone is different and this could have triggered something.

I would look for information on how to manage hypomania in the mean time. I would start tracking symptoms and mood for the purpose of discussing with a health care provider when you see one.
posted by lookoutbelow at 6:18 AM on November 28, 2022 [1 favorite]


Best answer: This sounds extremely scary and stressful. Wishing you both the best.

I was diagnosed with Bipolar Type 1 during a manic episode some years ago and prescribed lithium, quetiapine, and lamotrigine to stabilize. I was only on 50mg lamotrigine and stopped taking it cold turkey with my psychiatrist's consultation. No negative side effects. However, when I was trying to taper 100mg quetiapine I had to do it incredibly incrementally, down to 50mg to 25mg to eventually a tiny quarter crumb of 25mg in order to avoid incapacitating nausea and dizziness. I was stunned to realize how necessary that micro-tapering was. So another vote for trying to micro taper, or perhaps trying to go back to baseline at 200mg for now.

I'm concerned that your partner is actually experiencing mania, not hypomania. 2+ weeks is a long time. It took me about a month to finally check myself into the hospital, with many thanks to my caring and extremely worried partner.

Lamotrigine aside, my advice would be:
1. Sleep. As much as possible. When I was fully into my manic episode, I was averaging 0-4 hours a night, but it started with less and less sleep coupled with night sweats where I'd bolt awake and just had to get up and could not get back to sleep at all.
2. Stop the indica/weed. THC is psychotropic, and I also used to smoke regularly for anxiety. However, mixed with caffeine and alcohol and ESPECIALLY other meds, SSRIs, etc., I'm fairly certain that the combo kickstarted my mania and then, as I continued to vape more, it launched me into the stratosphere. While marijuana is safe for tons of people and in general I think weed is great and amazing, it's possible that it can exacerbate your mental/emotional state if you are already dysregulated.

> The concern would be she’d probably want to reinstate the med or even double down. It didn’t do anything for him at all (hence the SSRI trials) and we think it’s been contributing to some of his gastrointestinal problems…

From my perspective, at this point it seems like it would be a lot worse for the [hypo]mania to continue than to go back to baseline. I completely understand that you don't want to overwhelm the already stressed healthcare systems in place, but that was me, at the beginning: I tried and tried for weeks to get an appointment with a psychiatrist/doctor, didn't feel it was ever "emergency" enough to justify going to the ER, and eventually when I could no longer trust myself to drive and I could barely stand up (from lack of sleep), I checked myself into the hospital where they rapidly admitted me once I started screaming at my partner in a triage room. The agitation/restlessness may not seem life-threatening right now, but what you've described appear like serious red flags to me.
posted by derez at 4:18 PM on November 28, 2022 [1 favorite]


Best answer: I didn't see the thing about weed – DEFINITELY consider stopping that for now. Second what derez said about it, speaking from personal experience.
posted by lookoutbelow at 9:02 AM on November 29, 2022 [1 favorite]


Best answer: Couple more stray bits of advice:
- the hypomania coinciding with Lamotrigine withdrawal could be a coincidence, or a sign that the Lamotrigine has worked and he is no longer depressed, now slipping too far upwards without any med to prevent it
- SSRIs can cause hypomania in bipolar patients and I've seen psychiatrists strongly recommending against them, perhaps this is a lingering effect of some kind
- prepare for a period of depression after this to potentially set in
- has he tried lithium? Many bipolar folks swear by it and often psychiatrists will want to try it. I didn't like quetiapine and many people don't like drugs in that class. As I understand it lithium treats both bipolar depression and mania/hypomania, versus Lamotrigine which only treats the depression
- treat this as an emergency and go to the CAMH psychiatric emergency if you can't get another psychiatrist appointment within a couple days
- take harm reduction measures - if spending is an issue, change the Amazon password/put away credit cards, if he's spending lots of time texting or posting online, maybe put those aside to avoid any later-regretted oversharing or unusual behaviour, if there are any other risk-seeking behaviours or activities, take measures to avoid those

Wishing you the best in what must be a stressful time. The Canadian healthcare system is not good with stuff like this, and you may have to fight to get what you need.
posted by lookoutbelow at 10:37 AM on November 29, 2022 [1 favorite]


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