Risperdal withdrawal

[psychma]

I have a client with bipolar 1 disorder who has taken 6mg of risperdal daily for years. The medication has worked well for her but led to an 80 pound weight gain. The client has been working with weight management and taking Wegovy for 5 months with no weight loss at all. She quit her risperdal cold Turkey more than a week ago. Today, I noticed irritability and restlessness. The client has started having sleep difficulties. I reflected my observations today and expressed concerns for her health. She is only interested in losing weight and will not contact her doctor. How concerned should I be? I feel like this is a big deal and that she is at risk of paranoia, psychosis, and more. I’m not familiar with risperdal though really and don’t know what to expect from suddenly stopping. She does not have a psychiatry appointment for almost 3 months. What withdrawal symptoms should I watch out for? This will sound like a dumb question, but can sudden withdrawal be life threatening?

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[Stagg737]

No, sudden withdrawal from antipsychotics is not life threatening in a physiologic sense and antipsychotic "withdrawal" isn't really a thing. There can be some rebound-like effects from suddenly stopping antipsychotics, but this isn't a withdrawal like patients experience with illicit drugs or alcohol.

Yes, you should be somewhat worried as your patient sounds like they may be experiencing early signs of (hypo)mania. I would make sure to be monitoring for worsening manic symptoms and be doing safety evaluations at appointments going forward for possible need for inpatient admission.

 

[Doctorows]

In my experience, withdrawal symptoms following abrupt discontinuation of antipsychotics are fairly common. They may not be life-threatening, but they are very unpleasant to the patient. Anxiety, agitation, restlessness, insomnia are some of them and can be mistaken for a manic relapse.
Actual manic/psychotic relapse is usually the most concerning risk.

 

[Ceke2002]

Former patient who was also on Risperdal for a while here. Not a withdrawal in the same sense as coming off of benzos or opiates, but I do remember having some temporary trouble sleeping and just feeling like everything was ramped up (sight, sound, restlessness, etc). I was maintaining appointments and being pretty closely monitored at the time though, so it wasn't too big an issue for me. Lasted a couple of weeks from memory, and then settled down.

As others have said I think the main concern would be a return of and/or worsening of previous symptoms. When I was doing peer support work I certainly wouldn't have advocated for anyone I was working with to stop taking anti psychotic medication without first discussing it with their treating physician, and also being prepared to agree to additional monitoring of symptoms.

Weight gain with antipsychotics is obviously a very real concern to some patients. Is this patient open at all to exploring alternative medications for their condition? Anecdotal only, but I personally found Risperidal in wafer form (orally disintegrating) to be less weight effecting than the regular tablet form.

 

[Stagg737]

In my experience, withdrawal symptoms following abrupt discontinuation of antipsychotics are fairly common. They may not be life-threatening, but they are very unpleasant to the patient. Anxiety, agitation, restlessness, insomnia are some of them and can be mistaken for a manic relapse.
Actual manic/psychotic relapse is usually the most concerning risk.

Maybe semantics, but Idk that I've ever really thought about these as "withdrawal" symptoms as what you're describing is all more consistent with a dopamine rebound picture than "withdrawal". I conceptualize it as a kind of discontinuation syndrome like with SSRIs, although I've heard plenty of people call that "serotonin withdrawal". Regardless, abruptly stopping antipsychotics can be uncomfortable and cause some acute symptoms.

Antipsychotic Withdrawal Symptoms: A Systematic Review and Meta-Analysis

Avoiding withdrawal symptoms following antipsychotic discontinuation is an important factor when planning a safe therapy. We performed a systematic review and meta-analysis concerning occurrence of withdrawal symptoms after discontinuation of antipsychotics.We ...

www.ncbi.nlm.nih.gov

 

[ObsequiousAplomb]

Maybe semantics, but Idk that I've ever really thought about these as "withdrawal" symptoms as what you're describing is all more consistent with a dopamine rebound picture than "withdrawal". I conceptualize it as a kind of discontinuation syndrome like with SSRIs, although I've heard plenty of people call that "serotonin withdrawal". Regardless, abruptly stopping antipsychotics can be uncomfortable and cause some acute symptoms.

Antipsychotic Withdrawal Symptoms: A Systematic Review and Meta-Analysis

Avoiding withdrawal symptoms following antipsychotic discontinuation is an important factor when planning a safe therapy. We performed a systematic review and meta-analysis concerning occurrence of withdrawal symptoms after discontinuation of antipsychotics.We ...

www.ncbi.nlm.nih.gov

With opioids, the symptoms are because of sympathetic overdrive as a rebound from stopping the opioid. I don't really see much of a difference for the distinction it seems like you're making. Withdrawal is a rebound effect, I thought.

 

[comp1]

Return of what you were treating for is a lot more concerning that physiologic withdrawal. Make sure the patient knows about less metabolic options and that is all you can do until they destabilize to the point of being involuntarily treated.

 

[Celexa]

Doses to maintain stabilization are lower than what people come out of inpatient units on. A patient being on 6mg risperidone for years makes me wonder if they actually needed that much, if anyone ever bothered to have the downtitration conversation with them, or if they just got shuffled out of a 15 minute med visit where they were just chalked up as stable and the prescriber never reassessed whether changes were warranted. Plenty of patients maintain just fine on 1-2mg.

I use the discontinuation syndrome or symptoms language usually to differentiate from uncomfortable symptoms from stopping meds that aren't addictive or dangerous to stop suddenly.

 

[annoyedpsychiatrist]

usually pretty minimal in my experience when comparing to stuff like paxil/effexor/high dose SSRI withdrawl

 

[Stagg737]

With opioids, the symptoms are because of sympathetic overdrive as a rebound from stopping the opioid. I don't really see much of a difference for the distinction it seems like you're making. Withdrawal is a rebound effect, I thought.

It's not really a rebound of sympathetic overdrive though. A lot of the actual withdrawal symptoms are parasympathetic (yawning, GI stimulation/distress, several of the flu-like symptoms) and actual "withdrawal" isn't just a sympathetic response.

Antipsychotic "withdrawal" is also not a withdrawal as I've typically been taught by addictions mentors as the deficits in the reward system (LC, VTA, etc) leading to the withdrawal symptoms associated with cravings and seeking of the substance to maintain a minimal feeling of wellness aren't present. Other than seroquel I've never encountered anyone having "cravings" or demanding antipsychotics to maintain a baseline. Even with seroquel those individuals typically wanted it so they could keep using something else... I guess you can argue it's still withdrawal since it's the opposite effects with dopamine with antipsychotics so the physiological response is naturally going to be different, but "discontinuation syndrome" or "dopamine rebound" is just as apt and imo more accurate on a physiological and psychological level.

I guess if we're just defining withdrawal as a physiological response to a sudden lack of something then sure, I guess antipsychotic "withdrawal" is a thing. However, all the addictions docs I've worked with have a more specific definition of what withdrawal actually means though, which I tend to agree with.

Doses to maintain stabilization are lower than what people come out of inpatient units on. A patient being on 6mg risperidone for years makes me wonder if they actually needed that much, if anyone ever bothered to have the downtitration conversation with them, or if they just got shuffled out of a 15 minute med visit where they were just chalked up as stable and the prescriber never reassessed whether changes were warranted. Plenty of patients maintain just fine on 1-2mg.

I use the discontinuation syndrome or symptoms language usually to differentiate from uncomfortable symptoms from stopping meds that aren't addictive or dangerous to stop suddenly.

Agree with this, especially if this is a patient with bipolar disorder without another underlying psychotic disorder. I've rarely seen "pure" bipolar patients chronically require high doses of antipsychotics, and when they do there's usually a lot more going on.

 

[Candidate2017]

Return of what you were treating for is a lot more concerning that physiologic withdrawal. Make sure the patient knows about less metabolic options and that is all you can do until they destabilize to the point of being involuntarily treated.

OP is a "therapist" who has posted multiple threads about their overweight, female "client" self-DC'ing Risperdal. This thread probably needs to be closed for their own good because our responses help them avoid examining their countertransference, anxieties, and whether their therapy skillz are adequate. The focus on psychotropics is merely a form of intellectualization.

 

[Doctorows]

Maybe semantics, but Idk that I've ever really thought about these as "withdrawal" symptoms as what you're describing is all more consistent with a dopamine rebound picture than "withdrawal". I conceptualize it as a kind of discontinuation syndrome like with SSRIs, although I've heard plenty of people call that "serotonin withdrawal". Regardless, abruptly stopping antipsychotics can be uncomfortable and cause some acute symptoms.

Antipsychotic Withdrawal Symptoms: A Systematic Review and Meta-Analysis

Avoiding withdrawal symptoms following antipsychotic discontinuation is an important factor when planning a safe therapy. We performed a systematic review and meta-analysis concerning occurrence of withdrawal symptoms after discontinuation of antipsychotics.We ...

www.ncbi.nlm.nih.gov

Yes, I was refering to physiological response to an abrupt discontinuation of antipsychotic as withdrawal symptoms.

but this isn't a withdrawal like patients experience with illicit drugs or alcohol.

I would argue that the underlying mechanisms of both alcohol and antipsychotic withdrawal are quite similar: upregulation of D2 receptors with long-term antipsychotic use leads to supersentitivity of those receptors with abrupt discontinuation (so-called dopamine rebound) much like downregulation of GABA and upregulation of NMDA receptors with chronic alcohol use lead to CNS hyperexcitability which manifests as withdrawal symptoms when alcohol is abruptly stopped.

 

[psychma]

OP is a "therapist" who has posted multiple threads about their overweight, female "client" self-DC'ing Risperdal. This thread probably needs to be closed for their own good because our responses help them avoid examining their countertransference, anxieties, and whether their therapy skillz are adequate. The focus on psychotropics is merely a form of intellectualization.

Lol

 

[psychma]

I’m interested in psychotropics becaus so many (if not all) of my clients take them. I do a fair amount of reading to understand what they are taking. Call that intellectualization if you will. I appreciate the discussion points here. Thank you to those who have enlightened me. I have screened for suicidality and manic symptoms as a pretty typical thing to do. Client is reporting nausea and vomiting and I recommended calling her doctor and setting up a sooner appointment. I can’t make her do that but I can encourage it. There are things I don’t know about risperdal, like how soon one might see a return of symptoms. It would give me a timeframe to be more aware than I am. Trust me, I am looking at suicidal ideation/intent/plan as well as mania and paranoia pretty seriously. I know how to do my job. I was just curious about the risperdal but I can google it if my posts are so offensive. <rolls eyes>.

 

[psychma]

Doses to maintain stabilization are lower than what people come out of inpatient units on. A patient being on 6mg risperidone for years makes me wonder if they actually needed that much, if anyone ever bothered to have the downtitration conversation with them, or if they just got shuffled out of a 15 minute med visit where they were just chalked up as stable and the prescriber never reassessed whether changes were warranted. Plenty of patients maintain just fine on 1-2mg.

I use the discontinuation syndrome or symptoms language usually to differentiate from uncomfortable symptoms from stopping meds that aren't addictive or dangerous to stop suddenly.

This is a good point. I don’t know why she’s on 6 mg. She does take tegretol which interferes with the metabolism of risperdal from my research. A smaller dos might be reasonable but it is not my job to suggest any type of medication changes.

 

[psychma]

Return of what you were treating for is a lot more concerning that physiologic withdrawal. Make sure the patient knows about less metabolic options and that is all you can do until they destabilize to the point of being involuntarily treated.

This is my concern.

 

[Celexa]

This is a good point. I don’t know why she’s on 6 mg. She does take tegretol which interferes with the metabolism of risperdal from my research. A smaller dos might be reasonable but it is not my job to suggest any type of medication changes.

Suggesting medication changes is indeed out of your scope, but collaborating with the psychiatrist and letting them know the pt is really struggling with weight and at risk of stopping the med because of it is appropriate. Basically, if you are helping the psychiatrist understand the full clinical picture because you see the pt more often, that's great. Observing the boundary of not suggesting either to the patient or the psychiatrist specific medication changes is the critical piece.

 

[psychma]

To be honest, collaborating with psychiatrists can be difficult as also evidenced in this thread. I keep a short presentation and some are happy for the report. Many use their nurse as gatekeeper. She never answers the phone and you have to leave a message and never get a return call. I’m sure the dr is protecting their time but I feel uncomfortable leaving a message. I do it though. I think I’m feeling a certain burnout on people quitting their meds.

 

[ObsequiousAplomb]

To be honest, collaborating with psychiatrists can be difficult as also evidenced in this thread. I keep a short presentation and some are happy for the report. Many use their nurse as gatekeeper. She never answers the phone and you have to leave a message and never get a return call. I’m sure the dr is protecting their time but I feel uncomfortable leaving a message. I do it though. I think I’m feeling a certain burnout on people quitting their meds.

have you stopped to consider why you are putting so much effort into a case? The patient is supposed to be the one that puts forth effort, not you.
With my therapy patients, I don't give them the slightest thought between sessions. Where did you come to the idea you that you should?

 

[psychma]

have you stopped to consider why you are putting so much effort into a case? The patient is supposed to be the one that puts forth effort, not you.
With my therapy patients, I don't give them the slightest thought between sessions. Where did you come to the idea you that you should?

Yes, the patient does the work. I was really just curious as to what to expect. It was at the top of my mind because I saw her twice. There is a tendency in this forum to pathologize and question competency that I have noticed. I think I’ll leave my questions for google instead of trying to join in here.

Yes, I do think about clients between visits because I do weekly treatment planning. Before you criticize that, I have been praised by supervisors for being meticulous. I don’t spend my free time thinking about patients though. I do, however spend it reading about certain pathologies or medications.

 

[ObsequiousAplomb]

Yes, the patient does the work. I was really just curious as to what to expect. It was at the top of my mind because I saw her twice. There is a tendency in this forum to pathologize and question competency that I have noticed. I think I’ll leave my questions for google instead of trying to join in here.

Yes, I do think about clients between visits because I do weekly treatment planning. Before you criticize that, I have been praised by supervisors for being meticulous. I don’t spend my free time thinking about patients though. I do, however spend it reading about certain pathologies or medications.

Who's pathologizing and questioning competency?

Where did I jump to criticize? Seems an odd way to preface all your feelings.

 

[psychma]

Who's pathologizing and questioning competency?

Where did I jump to criticize? Seems an odd way to preface all your feelings.

I didn’t say you

 

[clausewitz2]

This thread seems to have turned in a very unproductive direction. Locking.