Can a patient stop or decrease a mood stabilizer?

Can a Patient Stop or Decrease a Mood Stabilizer?

No, mood stabilizers should not be stopped abruptly or decreased without careful planning, as discontinuation carries extremely high relapse risk—with over 90% of noncompliant patients experiencing recurrence, particularly within the first 6-10 months after stopping treatment. 1, 2, 3

Critical Evidence Against Discontinuation

The data on mood stabilizer discontinuation is stark and unambiguous:

• 87% of patients who discontinued mood stabilizers after 5 years of stability experienced recurrence, with median time to relapse of only 10 months 3
• More than 90% of adolescents who were noncompliant with lithium treatment relapsed, compared to only 37.5% of compliant patients 1, 2
• Withdrawal of maintenance lithium therapy dramatically increases relapse risk, especially within the first 6 months following discontinuation 1, 2

When Continuation is Mandatory

Mood stabilizers must be continued for at least 12-24 months after achieving remission from an acute episode, and many patients will require lifelong treatment when benefits outweigh risks. 1, 2

The American Academy of Child and Adolescent Psychiatry explicitly recommends:

• Maintenance therapy for a minimum of 12-24 months after the last mood episode 1, 2
• For patients with multiple episodes or severe presentations, lifelong treatment is often necessary 1, 2
• The medication regimen that successfully stabilized the acute episode should be maintained throughout this period 1, 2

If Discontinuation Must Be Considered

If discontinuation is absolutely necessary despite the high relapse risk, it must follow a specific protocol:

Prerequisites Before Any Taper:

• Patient has been completely stable (euthymic) for at least 12-24 months minimum 1, 2
• No recent manic, hypomanic, or depressive episodes 2
• Strong social support system in place 2
• Patient demonstrates excellent medication adherence history 2
• Immediate access to psychiatric care if symptoms return 2

Tapering Protocol:

• Taper extremely slowly over months, not weeks—abrupt discontinuation is contraindicated 4, 5
• Reduce dose by no more than 25% every 1-2 weeks at minimum, though even slower tapers may be necessary 5
• Monitor closely with weekly visits initially, then biweekly as taper progresses 2
• Use standardized symptom rating scales at each visit to detect early relapse 2

Monitoring During and After Taper:

• Weekly assessment of mood symptoms using validated scales 2
• Family/caregiver education about early warning signs of relapse 2
• Immediate plan for medication reinstatement if symptoms emerge 4
• Continue monitoring for at least 6-12 months after complete discontinuation, as this is the highest-risk period 1, 3

Special Considerations by Medication Type

Lithium:

• Lithium discontinuation carries particularly high relapse risk and should be tapered most conservatively 1
• Lithium has unique anti-suicide properties (reducing suicide attempts 8.6-fold and completed suicides 9-fold) that are lost upon discontinuation 1
• Abrupt lithium withdrawal can trigger rebound mania within days to weeks 1

Valproate/Divalproex:

• Gradual taper over 4-8 weeks minimum to avoid withdrawal symptoms 5
• Monitor for return of mood instability throughout taper 5

Lamotrigine:

• If discontinued for more than 5 days, must restart with full titration schedule rather than resuming previous dose to minimize risk of Stevens-Johnson syndrome 1
• Taper over several weeks when discontinuing 5

Carbamazepine:

• Taper gradually to minimum effective dose before considering discontinuation 6
• Attempts to reduce to minimum effective level should occur at least every 3 months during treatment 6

Common Pitfalls to Avoid

• Premature discontinuation before adequate duration of maintenance therapy (12-24 months minimum) 1, 2
• Abrupt cessation rather than gradual taper, which dramatically increases relapse risk 4, 5
• Inadequate monitoring during and after taper—weekly visits are essential initially 2
• Failure to educate patient and family about early warning signs of relapse 2
• Lack of immediate access to psychiatric care if symptoms return 2
• Discontinuing during high-stress periods or major life transitions 4

Alternative to Full Discontinuation

If the goal is to reduce medication burden or side effects, consider dose optimization to the minimum effective dose rather than complete discontinuation. 6, 5

• Systematic trials of dose reduction to find lowest effective dose 1
• This maintains some protective effect while potentially reducing side effects 5
• Still requires close monitoring but carries lower relapse risk than complete discontinuation 5

Bottom Line

The evidence overwhelmingly supports continuing mood stabilizers long-term rather than discontinuing them. The 87-90% relapse rate after discontinuation, even after years of stability, makes this one of the clearest recommendations in psychiatry. 1, 2, 3 If discontinuation is pursued despite these risks, it must be done with extreme caution, very gradual tapering, intensive monitoring, and immediate access to care for relapse management.