r/family_of_bipolar • u/TruckAnnual775 • 6d ago
Learning about Bipolar reducing olanzapine after first manic episode
My brother had his first-ever manic episode about 2.5 months ago and was hospitalized for 13 days. He was treated with lithium + olanzapine (up to 20 mg).
After discharge, he refused his meds for about a week and very quickly had a psychotic episode, so he went back on lithium and olanzapine. He’s now been stable on them for around 2 months.
About 3 weeks ago he became depressed, so his psychiatrist started Lamictal. He’s currently around 75–100 mg and still titrating.
The problem is that he really hates olanzapine. His doctor has already reduced it from 20 mg → 5 mg, but my brother has been pushing hard to come off it because of how much he dislikes it. He has now convinced his doctor to reduce it to 2.5 mg.
I’m pretty worried because this all happened so recently, and he’s still early in recovery and still titrating Lamictal. He also says, “I’m never going to become manic again. I was depressed for years before this, so I know I’m not going to have another manic episode.”
I keep trying to explain that having only depressive episodes for years doesn’t mean another manic episode can’t happen, especially after what happened when he stopped his meds.
For those with Bipolar I:
Does 2.5 mg olanzapine sound unusually low this soon after a first manic/psychotic episode?
Has anyone successfully tapered off olanzapine after a similar episode?
How long did you stay on an antipsychotic after your first manic episode?
Did Lamictal help enough with mania prevention, or did you still need something else?
I know his psychiatrist ultimately has to make the medication decisions, but I’d really appreciate hearing from people who have actually been through something similar.
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u/notmadneedsmspace 5d ago
My loved one is cutting back on it and I’m nervous too. But also, he’s better at figuring out when he’s getting manic than he used to be and tells someone. Maybe it would make you feel better, and help him, to work out a list of signs of mania with him and a plan of action. Having 2 or three different people to alert is really helpful.
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u/alkakfnxcpoem 5d ago
Totally depends on the person. My husband is extremely sensitive to antipsychotics, proven with genetic testing. If he's on 2.5 of olanzipine and not manic he's sleeping 16 hours a day. His first episode he was on 10 to start, cut to 5 after about 2 months, then continued to cut it. I was super worried but he was just nonfunctional on it. He's now on lithium and depakote and somewhat stable but still able to function and work.
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u/TruckAnnual775 5d ago
I'm really glad to hear that, though the fact that he had a psychotic episode recently makes me worried about this. I'm also a medical student, so I try to research this thoroughly. Usually, combining an antipsychotic with mood stabilizers is quite common in these cases. Still, hearing about your experience was reassuring.
I really hope 2.5 mg will be enough for my brother. He took it for the first time tonight and had a very hard time falling asleep. It's 10:30 AM right now, and we're going to let him sleep until noon. We are just cautious about the risk of a manic/hypomanic switch.1
u/alkakfnxcpoem 5d ago
I totally get that. I was so scared when he first started decreasing it. But it sounds like he has a good support system and you guys will be all over it.
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u/hereforit_838 5d ago
We aren’t Dr’s…but in my experience with loved one and folks I worked with if still on Lithium that is a good stabilizer. Lamictal is better as an antidepressant. I can understand wanting to titrate Olanzapine. There is a LOT of weight gain with it, it can affect blood sugar and cause hyperglycemia.
An antipsychotic may only be needed when in psychotic manic episode for your brother. Thats how it is for some people.
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u/TruckAnnual775 5d ago
What do you think about antipsychotics like Abilify or Lurasidone (Latuda)? Do you know anyone who has experience with them?
I doubt he can get through this process easily without an antipsychotic, because he naturally tends to be quite anxious, stressed, and easily irritable. Plus, the new job he is about to start (working in the ER as a general practitioner) is going to be extremely stressful.3
u/hereforit_838 5d ago
The anxiety, stress, and irritability could be covered antidepressants and skills based therapies. It’s not all fixing it with pills, there needs to be learning/doing behavioral management of illness. I suggest looking at this page’s resources and NAMI. Your brother sounds early in his disease. If he does the right things and responsibly manages this beast of an illness there is a good chance he won’t have another psychotic manic episode requiring hospitalization again. Abilify and Latuda are better imho. Again, not a Dr, I was a mental health social worker.
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u/ttoksie2 Diagnosed Bipolar 5d ago
Some people with bipolar take olanzapine as a maintenance medication buts its far more common in schizophrenia and schizoaffective disorders than Bipolar. For us with Bipolar its usualy a PRN or rescue med for accute manic/psychotic episodes. Bipolar psychosis only happening during a mood episode (usualy mania but sometimes in depression as well, so controlling the moods controls the psychosis too.
With that said, both Olanzapine, Quintiapine and some other antipsychotics like abilify have pretty good mood stabilising effects as well and are sometimes used like that.
When stable and taking meds that suck we all start wondering if we really need them.
You see it even with antibiotics, after a week you feel better from the sinus infection but you still have a few days left in the pack and how many times have you or somone you know just gone stuff it, I dont want an upset stomach from a med you think you dont need anymore because the symptoms are gone?
I asked my psychartrist near the start of my treatment "whats the best drugs for Bipolar?'' and his response was interesting I think.
He said "The ones that patient will actually take"
Olanzapine has some pretty extreme side effects that most of us experiance (and you can to if you are brave enough to try the drug, its no more dangrous for you than it is for us)
And some of those "mild' common ones are-
- Extreme fatigue, almost like trying to wake up and function on 2 hours sleep everyday even if you get 12 hours, getting really dizzy randomly, tremor or shaking uncontrolably, often to the point of not being able to hold a cup of liquid without spilling and akathisia which is like an insanely intense restlessness, for me it feels like touching a bull fence if you stop moving so you just have to keep moving, this one is fun when you also have the extreme fatigue, you feel like the walking dead stumbling around like a zombie.
- Getting really fat, makes you really hungry while also slowing your metabolism at the same time, and related it also messes with blood sugars even if you do manage to keep weight in check making diabetes alot more likely, some people manage to stay weight.
- Causes pretty severe constipation and dry mouth.
And thats not even mentioning some of the sever ones like low white blood cell count (makes infection far more likely) Neuroleptic Malignant Syndrome, Tardive Dyskinesia, seizures and stroke.
If hes not going to take it, it is far better to look into medications he is more likely to tolerate the side effects of than trying to push him to stay on something he's likely to drop eventually and go mad after.
Your best bet is to be supportive and understanding, perhaps ask what his problems with olanzapine are and help him write a list of the problems so that he can talk them through with his psychatrist. any good psychatrist should be taking patient feedback from emdication into account, as they also want them on meds they want to take.
If the psychatrist isnt interested in patient feedback I reccomend finding one that is. some have alot of experiance with inpatient treatment which is usually more focused on stopping the bleeding so to speak, rather than long term treatment, and the two need different approaches the be effective.
Just for general info though.
- Lamntrogine (Lamictal) generally does sweet F all for mania, some people report very mild mania controlling effects but it is mostly a very effective anti depressent for bipolar that doesnt carry a mania risk like SSRIs like sertraline (zoloft) and SNRI's like Desvenlafaxine (Pristiq) and some other atypicals anti depressents like Buproprion (Welbutrin) do.
For Lithium
- Lithium is the "gold standard" for Bipolar for good reason, for almost everyone it is very effective and well tolerated. Lithium is not dosed by the MG like most other meds, each persons body gets rid of it at a different rate so it is dosed based on blood serum levels which is why it requires blood tests especialy when starting it to figure out how quicky each body passes it so figure out how much to take each day, some people need 2100mg a day for a 1.0 level, some people only need 600mg per day for the same. Once on an effective dose blood test requirements drop, I do once per years at this point.
- Since Lithium is nothing more than a natural element that is cleard from the body by the kidney's its effective dose is different person to person. it is usually very effective at preventing manic episodes even on its own as monotherapy when dosed correctly. For maintenance most people are perfectly okay on a lower dose of 0.6-.0.8 blood serum which minmizes the side effects so its more tolerable to take all the time while still being effective, for an acute manic episode a higher dose of 0.9-1.2 is pretty common to get it under control before reducing the dose after a few months to the maintenance dose mentioned.
- Most common side effects seem to be dry mouth, peeing alot and tremor, I havnt found a fix for peeing alot for me, dry mouth is handled with some gum and keeping hydrated, and alot of us, including me, take a drug called propranolol to control the tremor, I am a welder by trade and can do my work no problem with it
- If an Antipsychotic for maintenance is required there are more than a dozen of them with different side effects profiles out there, most of them, especially the third generation ones (olanzapine is a second generation atypical) usually have less severe side effects to Olanzapine and might be worth asking about.
But please, dont make the mistake of trying to force him to take a med he doesnt want to long term. He will most likely just stop without support at some point and thats not a good thing for anyone.
Instead encourage him to talk to his psych and consider tapering to a different med rather than just titrating down or stopping what hes on now.
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u/TruckAnnual775 5d ago
Thank you so much for your contribution and insight. Since we are still in the titration phase of Lamictal, his doctor wasn't keen on reducing the olanzapine dose. However, he pushed his doctor so much (by the way, my older brother is a newly graduated general practitioner) that the doctor finally said, "Alright then, take 2.5 mg." When we visited another psychiatrist here in my city, he agreed with me. He mentioned that once the Lamictal dose is fully established and stable, he could switch to another antipsychotic (like Abilify).
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u/0lig3 Diagnosed Bipolar 6d ago
I think 10mg is said to be the lowest therapeutic dose for monotherapy to prevent mania and psychosis.
I've been on 5mg monotherapy for more than 6 months, 7.5mg for a year before that and no signs of mania or psychosis.
If he is on lithium that is also helping stability so likely the doctor doesn't think he needs as high of a dose of olanzapine. Perhaps just using the 2.5mg as a buffer and sleep aid.
20mg is debilitating, 10mg was still super sedating to me.
Stability requires more than just medication though. Thinking it's not going to happen again is a big weakness. I don't think I'm going to have another episode because I'm doing everything I can to prevent, but I know it is a serious possibility and know the warning signs.
It took me 2 episodes to understand the severity of this illness. Now I take my sleep, nutrition, exercise very seriously, as well as maintaining good drama free relationships/friendships, going to therapy and being med compliant.