Is tapering required when discontinuing divalproex (valproate) for mood disorders?

Tapering Divalproex for Mood Disorders

Yes, divalproex should be gradually tapered when discontinuing treatment for mood disorders to avoid withdrawal symptoms and prevent rebound worsening of mood symptoms, particularly mania. 1

Why Tapering is Necessary

Gradual tapering of divalproex is recommended to prevent two key complications:

• Rebound worsening of symptoms: Abrupt discontinuation can precipitate a return of manic episodes, as mood stabilizers like lithium and divalproex are particularly prone to causing rebound symptoms when stopped suddenly 1
• Withdrawal symptoms: Although specific withdrawal syndromes are less well-characterized for divalproex compared to other psychotropics, the general principle of slow tapering applies to avoid physiological discontinuation effects 1

Recommended Tapering Approach

Implement a gradual dose reduction of approximately 25% of the most recent dose every 1-2 weeks. 1, 2

Key tapering principles include:

• Duration: The taper should occur over weeks to months rather than days 1
• Slower for long-term use: Patients on higher doses or who have been on divalproex long-term warrant an even more gradual taper 2
• Flexibility: The taper rate must be determined by the patient's tolerance to dose reductions, not a rigid schedule—pauses in the taper are acceptable and often necessary when symptoms emerge 3

Critical Monitoring Requirements

Develop a clear monitoring plan before initiating the taper, as return of mood symptoms may take weeks to months to emerge after dose reduction. 1, 2

Monitoring should include:

• Frequent follow-up: Schedule appointments at least monthly during tapering, with more frequent contact during difficult phases 2, 3
• Watch for mood destabilization: Monitor specifically for return of manic or depressive symptoms, as bipolar disorder symptoms may not immediately recur 1, 2
• Extended observation period: Unlike ADHD medications where symptom return occurs in hours to days, mood disorder symptoms may take weeks to months to reemerge after the last dose 1

Special Considerations for Polypharmacy

If the patient is taking multiple medications, strategic sequencing matters:

• Keep the prophylactic agent: When choosing between two mood stabilizers, maintain the one with the most prophylactic efficacy or least long-term side effect potential 1
• Taper adjunctive agents first: If divalproex was added as augmentation to another mood stabilizer, consider tapering divalproex first while maintaining the primary agent 1
• Benzodiazepine priority: If the patient is taking both divalproex and a benzodiazepine, taper the benzodiazepine first due to higher withdrawal risks including seizures 2, 3

Common Pitfalls to Avoid

• Discontinuing in unstable settings: Avoid initiating tapers during inpatient or partial hospital stays with short lengths of stay, as this may result in unmonitored return of symptoms after discharge 1
• Inadequate history review: Before discontinuing, obtain thorough history of previous psychiatric symptoms and medication response—reviewing medical records and discussing with previous prescribers prevents needless symptom recurrence 1
• Premature discontinuation: Ensure the patient has been stable and may no longer need medication before initiating a taper, rather than discontinuing based solely on side effects or prescriber preference 1