How do I taper a patient with schizophrenia, bipolar disorder, and major depressive disorder off risperidone (antipsychotic) who is currently on trazodone (antidepressant) and wants to resume their previous medication?

Tapering Risperidone in a Patient with Schizophrenia, Bipolar Disorder, and Major Depressive Disorder

Gradually taper risperidone over 2-4 weeks by reducing the dose by 25% every 1-2 weeks, while discontinuing trazodone abruptly (as it is not treating the primary psychotic disorder), and only restart the patient's previous medication after risperidone is fully discontinued. 1

Rationale for This Approach

The key principle here is that when a patient is on multiple medications, you should remove the medication used adjunctively first, while maintaining the medication with the most prophylactic efficacy for the underlying severe disorder 1. In this case:

• Trazodone can be stopped without tapering since it was added as an adjunctive agent and has minimal antipsychotic properties—studies show trazodone has no proven antipsychotic action in schizophrenic patients 2
• Risperidone requires gradual tapering to avoid withdrawal symptoms and rebound worsening of psychotic and manic symptoms, which is particularly important given this patient's schizophrenia and bipolar disorder 1

Specific Risperidone Tapering Protocol

Based on FDA labeling and clinical guidelines, follow this schedule 3:

• Week 1-2: Reduce risperidone dose by 25% of the current total daily dose
• Week 3-4: Reduce by another 25% (now at 50% of original dose)
• Week 5-6: Reduce by another 25% (now at 25% of original dose)
• Week 7-8: Complete discontinuation

For example, if the patient is on risperidone 4 mg daily:

• Weeks 1-2: 3 mg daily
• Weeks 3-4: 2 mg daily
• Weeks 5-6: 1 mg daily
• Weeks 7-8: Discontinue 4, 5

Critical Monitoring During the Taper

You must monitor weekly for the following 4:

• Psychotic symptoms: Hallucinations, delusions, disorganized thinking
• Manic symptoms: Elevated mood, decreased need for sleep, increased goal-directed activity, impulsivity
• Depressive symptoms: Mood, suicidal ideation, sleep, appetite
• Withdrawal symptoms: Anxiety, insomnia, irritability, dizziness, nausea (typically emerge within days)
• Extrapyramidal symptoms: May paradoxically worsen temporarily after discontinuation 1

When to Resume the Previous Medication

• Do not start the previous medication until risperidone is completely discontinued to avoid antipsychotic polypharmacy, which should only be used as a last resort after clozapine has failed 6
• If severe psychotic or manic symptoms emerge during the taper that pose safety concerns, return to the previous risperidone dose and extend each reduction phase by 1-2 weeks 4
• Once risperidone is fully discontinued, the previous medication can be initiated at its standard starting dose 3

Common Pitfalls to Avoid

• Do not stop risperidone abruptly—this can trigger severe rebound psychosis or mania, particularly dangerous in patients with schizophrenia and bipolar disorder 1
• Do not misinterpret withdrawal symptoms as relapse—withdrawal symptoms typically emerge within days and are self-limiting, whereas true relapse develops more gradually over weeks 4
• Do not start the previous medication while still on significant doses of risperidone unless you are intentionally pursuing antipsychotic polypharmacy, which requires specific justification 6
• Do not declare the taper a failure prematurely—some patients may require slower tapering (extending to 8-12 weeks) if withdrawal symptoms emerge 4

Special Considerations for This Patient

Given the complex diagnostic picture (schizophrenia, bipolar disorder, and major depressive disorder):

• The underlying psychotic disorder (schizophrenia) is the most severe and impairing condition and must remain the treatment priority 1
• Risperidone is FDA-approved for both schizophrenia and bipolar mania at doses of 1-6 mg/day for adults, making it appropriate for this patient's conditions 3
• If the patient insists their previous medication worked better, ensure you have verified this through medical records and previous prescriber contact before proceeding with the switch 1
• The patient's adamant preference should be respected as long as the previous medication is appropriate for their diagnoses and the switch can be done safely 1