Dshine: Moving the Psychiatric med around the day or keep the Mirtazapine for sleep? Gogo’s story

[Dshine]

Hello, I've just recently found this site and kept reading and absorbing all kinds of information. I am so glad to read so many inspiring stories and would like to share my son’s story.  

 

On Nov 2022 last year, my son, Gogo, a recent college graduate and athletic, who has been suffering insomnia since pandemic began was put in Psychiatric hospital for 3 nights after emotional breakdown in public place.  Police said he trespassed and his speech was not coherent. He was prescribed Risperidone 1mg in the morning and 1mg at night, 250mg Depakote in the morning and 500mg Depakote at night, as well as 7.5mg Mirtazapine in the evening for helping sleep.

 

When he was discharged from hospital, we saw his speech was disorganized and had deliriums kind of symptom most in the earlier morning and evening sparsely.  I thought it was due to the shock by police and medications.  So I tried to reduce his med several time, but the symptoms didn’t go away. I paid to ask online psychiatric doctor about it  and I got an answer said he most likely has schizoaffective disorder.  After I was convinced that his breakdown most likely caused by his sleep deprivation and self medication with recreational drugs, I become more adapted with his continuation of those medications. But I don’t think he has schizophrenia. He still not has any diagnosis. He started to sleep better with those meds but most of day time is tired and lethargic.  He was not doing well for his online class because of the lethargy caused by the meds. He was also diagnosed with mild sleep apnea short after discharging from hospital.

 

We don’t have psychiatric doctor for almost 4 month after discharge from the hospital. But we tried to tape Resperidone especially, after consulting a friend who is neuron doctor, but failed, scared by the relapse of symptoms like self occupation and mood issue. I know now from here that the taping is way too fast.

 

We are like walking in the fine line or water with medication management, and still now.   His PCP only manage his Mirtazapine.  I’m going to tell later what his PCP’s taping strategy for Mirtazapine.

 

On 2/26  still suffering depression and sadness, and noticed that his chest is painful, Gogo insisted not taking any medication. I learned some knowledge about withdraw symptom from online, but find noting about detailed strategy. So my son and I agreed  to stop taking the morning med. For the first 2 weeks, he become lively and being more like old himself I know, and had lots of self reflection of the past but more connected, even sometime he experienced strong emotions. But on 3/15, he has another emotional breakdown after visiting a friend. We decided he was not appropriate to drive and take him back in our own car.

 

After this incident, with my knowledge from online study and search, I knew that we may withdraw too fast. Then he started to take the morning meds every other day. I know now it’s another mistake.  We did that, and only realize not so late that it make thing worse in a few days. It seems fine for the first few days, then one day he insisted to drive himself without abling to speak logically and express his feeling. He was indecisive when driving. We reinstate to the original dose fully. Actually, I know now that  we could have reinstate to lower doses, but we have no guidance. His pcp is not able to offer any help with his psychiatric meds except for Mirtazapine.  I just wish we could find the site earlier. Only when I included the word ‘tape” instead “reduce” or “withdraw"  in my search that I found this site.

 

On 2/26,   Following his PCP taping strategy for Mirtazapine, he started to take 7.5mg mirtazapine every other night for 4 weeks, till 3/26, then 7.5mg twice a week for 3 weeks till 4/18. His sleep seems fine with every other day’s  7.5mg mirtazapine. However, during the twice of week 7.5mg mirtazapine period, he started waking up in the middle of night because almost at the same time he started to taping 250mg evening  Depakote on 3/30 following a RN's advice.  I think that is another mistake to tape the evening Depakote first.

 

We also finally saw a Psychiatrist on March, who recommend my son to take all 2mg Resperidone in the evening to avoid his daytime lethargy. We are reluctant to do that considering his most recent unstable situation. The Psychiatrist talked to me and asked why, I said I am afraid that the moving medication around the day might make my son unstable again.  I shared my son’s med log to her and it seems she never read it. She also email me that she never heard of  Resperidone withdraw symptom.  She then said how about reduce the morning to 0.5mg. In a mind that want to tape all meds, we took it as she want to tape my son’s Resperidone. So Guoguo took 0.5mg in the morning and Kept 1mg in the evening.  It came strong resistance from his Grandma. So I waited for few days before I reduce the morning dose, started reduction on the next Monday after seeing the psy doctor. During the following Thursday appointment with psy doc,  my son told her he is doing fine after 3 days 0.5mg Resperidone in the morning . I again see my son begin  to come back to be himself, having back his sense of humor, etc. But the weekend is a mix feeling. We went to outing, he was happy and enjoying the trip with friend. But on the way back, he started to show self-occupied without talking here and there, easy to get angry with small things. We start to reinstate his 1mg Resperidone the next morning. During the next appointment, we found out that his psy doc actually want to him to take 1.5mg Resperidone in the evening. She did NO intent to tape.  I was so frustrated that why she did not emphasize that to keep the current daily doses unchanged. I also blamed myself for not asking for clarification with his Doc because I was so eager to get him out of those meds.  She said we could continue as we have done like 2mg twice a day.  She was also very unhappy we didn’t follow her advise, as well seeing an RN.  My son did not have an appointment with her last week. I think we are going to find another one.

 

We went to RN again, she gave us 3 options, 1) Go back to take 7.5mg Mirtazapine in the evening or 3.75mg  2) Reinstate the original Depakote of 750mg a day.  3) Move the morning 250mg Depakote into the evening, no Depakote in the morning.

 

Concerning with moving the medication from morning to evening might make my son unstable, we choose to add  3.75mg  mirtazapine because my mom is doing really well on that dose for a year and eventually taped off.

 

A few nights he seems well with 3.75mg mirtazapine not waking up, but felt very tired and sleepy in the day. He stopped taking for few days because of that. But that makes him woke up in the middle of night. We also add megnesium 150mg 3 times a day, along with 50mg B6 twice a day and 1.5mg melatonia in the bed time.  He went back to  3.75mg mirtazapine again and had only few night not waking up. One night he is so tired and not want to have Mirtazapine and any supplements. But I observe that he is doing fine when waking up.  He had two nights not having mirtazapine, his mood seems fine. It seems for me he woke up feel good for those 2 nights without taking mirtazapine.  Even he woke up earlier, but he has quality sleep in the first half of night.(we use apple watch to monitor sleep cycle, it’s said AW is close to EEG study). The day before yesterday, he woke up 5pm and stay in the bed for an hour and got up with good mood and took a nap in the afternoon. But he is not having a good sleep yesterday with 3.3g mirtazapine.  It was 3.3mg because he did not take mirtazapine the previous 2 days. It’s the right dose? I read here that we need to keep the same dose and same time, some time we dont have the medication at the same time specially in the morning as my son is very hard to get up in the morning becasue of sleep issue.

 

My son really wants to tape all of his medications, which make him gaining almost 20lb for an athletic as him in 3 months.   That’s why he  agreed to do Keto diet on 3/20.  But after the outing incident in front of his friend, he told me he might need take all these med for his life. I said to my son that you don’t need to.  I’m sure you will have good sleep without any of those med some time soon and enjoy your life drug free.  When my son is stable with Depakote and his sleep, I believe he can start with taping Resperidone.

 

Now just stuck with this Mirtazapine issue and sleep issue, do you think Gogo should take half of the 7.5mg or reinstate to 7.5mg or just stop taking Mirtazapine completely. I'm  reluctant to let my son go back to original dose of 7.5mg, which make him gaining so much weight and sleepy during the day.   Or take one of the NP advice to keep current doses unchanged and move morning 250mg to evening to make  500mg Depakote in the evening?  Or move the Resperidone around to the evening to make him sleep better and less sedated in the day?

 

BTW, I got a jewry scale from the recommendation link here for Mirtazapine 3.75mg,  it rounds to 0.0mg, and too sensitive, reading often changes. I still have no clue how to do the liquid form for small doses,  any advise will be helpful.

 

Thank you for bearing me and appreciate so much for your help. 

 

Best Wishes,

 

Dshine

[Shep]

Hi, @Dshine

 

Welcome to Surviving Antidepressants. You're being a great advocate for your son. He's lucky to have you.

 

As noted in our PM conversation, you already asked your son to join us, but for now, he's unable to do so, but he is going to be able to do a drug and symptoms journal, which you can post for him here in your introduction/update thread. 

 

Please go ahead and list the past few days of notes. Here is what we need:

 

Keep notes on paper about your daily symptom pattern and drug dosing

 

Also, please set up a signature for your son's drug history. Here is how:

 

How to Summarize Your Drug History in Your Signature

 

Please note in your signature that this is for your son. 

 

Please continue to use this thread to document your son's taper and recovery and to ask questions. We hope that Gogo is feeling better soon and will be able to join us. We welcome both of you here. 

 

 

[Dshine]

Hi Shep, 

Appreciate your kind and encouraging words. You own story I read recently speaks so much and resonate to me too.   I just updated the signature. As for Gogo's joining, I’m little concerned about him seeing my post here. If he could join by himself without me,  that will be the best. I’ll try to communicate with him little by little so he would understand what I am doing is not to expose his private as he has been very open to me about his thoughts and feeling. I treasure that relationship and hope it will be part of his healing to redeem back his time lost.   

 

The journal is attached here for yesterday’s one. I really like what you said in your successful story that the symptom can serve as our teachers. I told Gogo keeping the journal is part of endurance journey toward victory.   Hopefully he can keep doing it everyday as accurate as he can. 

Thanks again, 

Dshine

 

	5/9/2023
	Meds/Sup	Feeling/Symptoms
8:30 AM
9:00 AM
9:30 AM
10:00 AM	Risperidon 1mg/dep 250mg	woke up but stay in bed, sleepy
10:30 AM
11:00 AM
11:30 AM		got up, breakfast
12:00 PM	meg 50mg/50mg B6,	tire, anxiety, etc.
12:30 PM
1:00 PM
1:30 PM	meg 50mg/50mg B6, Fishoil
2:00 PM		on phone
2:30 PM		tired
3:00 PM		tired
3:30 PM	watched a movie	tired
4:00 PM		tired
4:30 PM		tired
5:00 PM	Chichen Lettuce wrap	tired
5:30 PM		tired
6:00 PM		tired
6:30 PM		tired
7:00 PM	Dinner, 2 chicken wings and bokchoy	pretty energized, just came back from a walk
7:30 PM	Risperidon 1mg/dep 250mg	had a lot of energy
8:00 PM	went out for a walk/exercise	had a lot of energy
8:30 PM		yawn 2 times, tired
9:00 PM		wasn't too tired, moderate energy
9:30 PM		tired, went to bed for a little bit
10:00 PM	Ate some food, kimchi and salami Mirtazapine 3.75mg/meg 50mg/B6 25mg	yawned twice, but no so tired anymore
10:30 PM		tire, Bed time, light off
11:00 PM
11:30 PM

[Dshine]

FYI: This is part of PM regarding having Gogo’s joining, and a change regarding a term used in above introduction.  

 

"Hi Shep, I talked to Gogo, he initially said no but I’m going to communicate with him more about it. Now he is willing to record his symptoms and meds check everyday by himself. It has started from day one today.  I’ll update to you. 

Regarding the post I send, where in one section I mentioned delirium once, I believe I used the wrong term for it as it’s complete strange behavior for us.  By reading through posts here, I finally realize that is Akathisia, induced by  the meds he took for 3 days. But Gogo was not aware of that even though we let him know about it few times.  He just tried to deny. "

[Dshine]

1 hour ago, Dshine said:

 

Forgot to add Melatonin to yesterday's 10pm bed time meds/supplements:  Here is the complete night time sleep med list: 

2mg Melatonin, 50mg Mag Glycinate, 25mg B6 and 3.75mg Mirtazapine.

Gogo have been taking 1.5mg Melatonin for about a week. Just increased from yesterday. I've also kept a Meds/notes log for Gogo, but don’t have the hourly breakdown. If it’s helpful, I can send here. 

Edited May 10, 2023 by Dshine
correcting a mistake/ make it more easy to see/understand

[Shep]

13 hours ago, Dshine said:

Hi Shep, 

Appreciate your kind and encouraging words. You own story I read recently speaks so much and resonate to me too.   I just updated the signature. As for Gogo's joining, I’m little concerned about him seeing my post here. If he could join by himself without me,  that will be the best. I’ll try to communicate with him little by little so he would understand what I am doing is not to expose his private as he has been very open to me about his thoughts and feeling. I treasure that relationship and hope it will be part of his healing to redeem back his time lost.   

 

The journal is attached here for yesterday’s one. I really like what you said in your successful story that the symptom can serve as our teachers. I told Gogo keeping the journal is part of endurance journey toward victory.   Hopefully he can keep doing it everyday as accurate as he can. 

 

Thank you for working with your son to get his journal started. This is exactly what we need. Very well done. Please convey to Gogo that he is doing exactly what he needs to do. 

 

Please note that some of his symptoms may be drug interactions. I've placed his three psychiatric drugs in an online drug interaction checker and here are the results:

Drug Interaction Checker Report - Risperidone, mirtazapine, depakote

 

It may help to separate these drugs from one another by at least 2 hours. We recommend doing this gradually by moving the drugs only one hour a day. To separate them by two hours, you would move them apart one hour today and one hour tomorrow. 

 

He could do this over the next couple of days and then hold everything steady as he continues his journal. It make take a few days or weeks for his nervous system to settle down, but hopefully this will reduce some of his symptoms. 

 

12 hours ago, Dshine said:

2mg Melatonin, 50mg Mag Glycinate, 25mg B6 and 3.75mg Mirtazapine.

 

2 mg of melatonin may be too high. Please see at least the first post in this thread:

 

Melatonin for sleep

 

Because he's taking sedating supplements while taking a sedating drug, he may experience paradoxical reactions - the more you dampen down the brain with sedating drugs and / or supplements, the more the brain fights to stay alert. This is called a paradoxical reaction. If Gogo feels that is happening, he may want to reduce the melatonin. 

 

I noticed that Gogo was trying to come off his drugs by skipping days. Please note we do not recommend doing this. Please see:

 

How about taking my medication every other day to reduce my dosage? DO NOT TAKE YOUR MEDICATION EVERY OTHER DAY TO TAPER.

 

Ideas for helping Gogo stabilize:

 

• If he feels the melatonin is too high, he can reduce it back down.
• Separate the drugs by at least 2 hours to reduce any potential drug interactions.
• Go into a hold and continue with his drug and symptoms journal
• Please include the number of hours of sleep in the journal

IMPORTANT! - please note - it's important to only make one change at a time. If he changes the melatonin dose, that's a change. If he moves his drugs to prevent drug interactions, that's a change. Please see:

 

The rule of 3KIS: Keep it simple. Keep it slow. Keep it stable.

 

Please continue to post Gogo's journal and encourage him to join us here when he's ready. 

[Dshine]

8 hours ago, Shep said:

 

 

It may help to separate these drugs from one another by at least 2 hours. We recommend doing this gradually by moving the drugs only one hour a day. To separate them by two hours, you would move them apart one hour today and one hour tomorrow. 

 

He could do this over the next couple of days and then hold everything steady as he continues his journal. It make take a few days or weeks for his nervous system to settle down, but hopefully this will reduce some of his symptoms. 

If starting change to one hour apart between the two meds, how many days to hold one-hour-apart change before changing to two-hour-apart? You mean Gogo actually can move to the 2 hour apart tomorrow if he starts to move them apart one hour today? 

8 hours ago, Shep said:

 

MPORTANT! - please note - it's important to only make one change at a time. If he changes the melatonin dose, that's a change. If he moves his drugs to prevent drug interactions, that's a change. Please see:

 

The rule of 3KIS: Keep it simple. Keep it slow. Keep it stable.

 

Thank you for such a detailed instruction.My question is as Gogo is taking his med two times a day, does morning change (moving drug one hour apart) count as one?  And evening hour change count as another?

 

He already took the morning med altogether. We may start the evening one to move hour apart. 

 

Yesterday he said he woke up at 2am but fell back to sleep without getting up. It sounds he is happy for that. So he may keep the 2mg melatonin. He got up at 9:30am himself that is a good sign as he alway stays in the bed till noon to feel normal and awake. 

[Dshine]

			5/10/2023
			Med/activity/Sleep	Feeling/Symptom
8:30 AM			Sleep:woke up at 5am, managed back to sleep
9:00 AM
9:30 AM
10:00 AM
10:30 AM
11:00 AM
11:30 AM			took risperidone 1 mg/depakote 250 mg	got up, felt tired
12:00 PM			ate breakfast	felt awake
12:30 PM			watching a movie	felt normal
1:00 PM
1:30 PM
2:00 PM				Ate flaxseed Porridge
2:30 PM
3:00 PM			Got massage	Felt tired
3:30 PM
4:00 PM			Finished massage	Felt tired
4:30 PM				Did 10 reps Myofunctional, yawned 3 times
5:00 PM			Went toTrader Joe's	Felt energetic and happy and excited
5:30 PM
6:00 PM			Made miso soup and read the Bible	Felt energetic, focused and happy
6:30 PM
7:00 PM			dinner,beef stew and borocoli
7:30 PM			Risperidon 1mg/dep 250mg	Felt a little tired
8:00 PM			Watching a movie/ChiaSeedSmoothie(1 cup)	Felt normal
8:30 PM				Felt normal
9:00 PM				Felt normal
9:30 PM			MagGlycinate 50mg/Melatonin2mg/Mirtazapine 3.75mg/B6 25mg	Felt normal
10:00 PM			made bed	Felt tired and full
10:30 PM			Bed time light off	Felt tired
11:00 PM
11:30 PM

[Dshine]

Today’s update: after breakfast at 10am, felt to sofa and slept for another 2 and half hour. Upon waking up, Gogo said he wants to stop taking the mirtazapine 3.75mg tonight.  He think it’s the 3.75mg  Mirtazapine made him sleepy during the day, his PCP told him before that the lower dose of Mirtazapine have more sedated effect.  

 

May 19th will mark one month of 3.75mg Mirtazapine, may be we can hold the current 3.75mg Mirtazapine till 30 days and further taper down afterward. 

 

[Dshine]

Hi Shep,  updated journal is attached.    

 

Gogo is going to see his NP tomorrow. Do you think it’s good ideal we can talk to his NP about tapering  Risperidone next while holding current Depakote doses? 

 

Thank you! 

 

Dshine

 

 

Journal-Gogo.numbers

[Shep]

13 hours ago, Dshine said:

If starting change to one hour apart between the two meds, how many days to hold one-hour-apart change before changing to two-hour-apart? You mean Gogo actually can move to the 2 hour apart tomorrow if he starts to move them apart one hour today? 

Thank you for such a detailed instruction.My question is as Gogo is taking his med two times a day, does morning change (moving drug one hour apart) count as one?  And evening hour change count as another?

 

 

Technically, these are two moves (morning and night), but if he's already made the changes by now, that's okay. He may want to hold a week or so to see how he does after separating both sets (morning and evening) two hours apart. 

 

10 hours ago, Dshine said:

Today’s update: after breakfast at 10am, felt to sofa and slept for another 2 and half hour. Upon waking up, Gogo said he wants to stop taking the mirtazapine 3.75mg tonight.  He think it’s the 3.75mg  Mirtazapine made him sleepy during the day, his PCP told him before that the lower dose of Mirtazapine have more sedated effect.  

 

May 19th will mark one month of 3.75mg Mirtazapine, may be we can hold the current 3.75mg Mirtazapine till 30 days and further taper down afterward. 

 

 

I would come off the risperidone morning dose before reducing the mirtazapine. If he's tired during the day, the best thing to do is get off any sedating drugs he's taking during the day first. 

 

1 hour ago, Dshine said:

Hi Shep,  updated journal is attached.  

 

Please copy and paste his journal instead of attaching it. We have limited space for attachments on this site, so having the information in a post is best. 

 

1 hour ago, Dshine said:

Gogo is going to see his NP tomorrow. Do you think it’s good ideal we can talk to his NP about tapering  Risperidone next while holding current Depakote doses? 

 

Yes, tapering risperidone sounds like a good plan. Here is the information:

 

Tips for tapering off risperidone (Risperdal)

 

Why taper by 10% of my dosage?

 

The Windows and Waves Pattern of Stabilization

 

Please let Gogo know that risperidone comes in a liquid solution. He should ask his PCP to prescribe it, as that's the easiest formula to taper.  If he does get a liquid solution to taper, he'll want to gradually switch over to liquid before making any reductions. We recommend switching from tablet to liquid by 25% increments. So 25% liquid, 75% tablet. Then 50%/50% split. And then 75% liquid and 25% tablet and then 100% liquid. He should hold for a few days in between changes. Again, the switch should be at the full dose without making any reductions until he sees how he feels on the liquid. 

 

I would encourage you both to read through all three links prior to Gogo's appointment. He may also want to read this before speaking with his prescriber:

How do you talk to a doctor about tapering and withdrawal?

 

Also, Gogo should get started on learning non-drug techniques for handling his symptoms. There are many to choose from. As he decreases the daytime sedating drugs and feels better, having some healthy activities that encourage neuroplasticity and healing will really help him recover. Here are some ideas:

 

Non-drug techniques to cope with emotional symptoms

[Dshine]

Wow, there are lots to learn. Thank you so much, those info are really helpful.  

 

14 hours ago, Shep said:

 

How do you talk to a doctor about tapering and withdrawal?

 

Also, Gogo should get started on learning non-drug techniques for handling his symptoms. There are many to choose from. As he decreases the daytime sedating drugs and feels better, having some healthy activities that encourage neuroplasticity and healing will really help him recover. Here are some ideas:

 

Non-drug techniques to cope with emotional symptoms

The appointment was changed to next week as it’s hard in the morning. But it gives Gogo more time to read through and prepare to talk to his doctor. Also found this article online about antipsychotic tapering. https://academic.oup.com/schizophreniabulletin/article/47/4/1116/6178746

 

14 hours ago, Shep said:

Please copy and paste his journal instead of attaching it.

5/11/2023C

Med/Sleep/Feeling/Symptoms

8:30 AMWoke up at 2 am, belly felt full, couldn't go back to sleep, but eventually fell asleep until 7 and then stayed in bed until 9amFelt tired 

9:00 AMFelt tired 

9:30 AMFelt tired 

10:00 AMTook risperorone/depakote Felt tired 

10:30 AM
Ate breakfast, Meg 50mg/50mg B6/Fish-oil/mutiple VTMFelt normal 

11:00 AM

11:30 AMTook a nap, tired 

12:00 PMTook a nap, tired 

12:30 PMTook a nap, tired 

1:00 PMTook a nap, tired 

1:30 PMWoke up, felt a little more energetic 

2:00 PMAte lunch Felt more awake 

2:30 PMMeg50mg/FoliaAcid1mg

3:00 PM

3:30 PMFelt energetic, went to go swimming 

4:00 PMFinished swimming, felt energized 

4:30 PMWent to the gym and worked out, 

5:00 PM

5:30 PMFinished the workout, felt energized and good 

6:00 PMFelt energized and happy 

6:30 PM

7:00 PMtook a walk withGM

7:30 PMRidperidone 1mg

8:00 PM

8:30 PMDepakote 250mgRead the Bible and prayed, felt good and positive 

9:00 PM stressed 

9:30 PM phone call

10:00 PMMagGlycinate 50mg/Melatonin2mg/B6 25mgSkipped the Mirtazapine for tomorrow morning appointment,  online test

10:30 PM3.75mg Mirtazapine(tried to Skip the Mirtazapine for morning tasks, but took back for consistancy) Bed time light off

 

Here is the yesterday one. Gogo woke up in the morning irritated and said not having good sleep.  I guess moving the Depakote one hour later in the evening caused some stress. And having Depakote closer to the bedtime may add paradoxical reaction?  We may reduce the melatonin tonight and keep the med one hour apart like yesterday. And Gogo may want to keep the way he takes morning med unchanged until his sleep is getting better. 

 

Appreciate all the help! 

[Dshine]

Dear Shep, Gogo did not move his dose apart and took the evening med same time today like he always does,  but reduced the Melatonin to quarter of 3mg, about .8mg.   Does it counte as 2 changes? May be just  to move his morning doses one hour apart first, and keep his evening pattern unchanged so that he would have a stable sleep?  How do you think so? 

[Shep]

9 hours ago, Dshine said:

Also found this article online about antipsychotic tapering. https://academic.oup.com/schizophreniabulletin/article/47/4/1116/6178746

 

Yes, that's an article we're familiar with here. One of the co-authors, Dr. Mark Horowitz, is well-known within the de-prescribing community. We have a thread about this study here in our Scientific Journals section. Manymoretoday's linked to an earlier study in the second post in this thread:

 

A Method for Tapering Antipsychotic Treatment That May Minimize the Risk of Relapse

 

9 hours ago, Dshine said:

Here is the yesterday one. Gogo woke up in the morning irritated and said not having good sleep.  I guess moving the Depakote one hour later in the evening caused some stress. And having Depakote closer to the bedtime may add paradoxical reaction?  We may reduce the melatonin tonight and keep the med one hour apart like yesterday. And Gogo may want to keep the way he takes morning med unchanged until his sleep is getting better. 

 

There were a number of things that may have caused poor sleep. Let's go through these.

 

• He waited until 10:30 AM to have breakfast, even though he was awake several hours earlier. Some of his early morning symptoms may have been early morning cortisol but it also may have been low blood sugar, since he hadn't eaten since the night before. He may want to eat a healthy breakfast soon after he wakes up. This would be a breakfast high in protein and no sugar. This will set the stage for a much better day overall. 
• He exercised in the late afternoon. It's wonderful to see him so energized and happy, but he may want to exercise earlier in the day, as many people find exercising in the afternoon and evening can be too stimulating and negatively affect sleep. 
• He moved the Depakote one hour, as noted in the above quote box, but he also tried to avoid taking the mirtazapine and ended up taking it, but a bit later, if I'm reading his journal notes correctly. He was likely frustrated that he needed it, which may have caused some psychological angst, setting the stage for a poor night's sleep. 

I mentioned early morning cortisol in that first bullet point. Here is a link with some tips to handling the morning symptoms:

 

Early-morning waking - managing the morning cortisol spike

 

 

3 hours ago, Dshine said:

Dear Shep, Gogo did not move his dose apart and took the evening med same time today like he always does,  but reduced the Melatonin to quarter of 3mg, about .8mg.   Does it counte as 2 changes? May be just  to move his morning doses one hour apart first, and keep his evening pattern unchanged so that he would have a stable sleep?  How do you think so? 

 

There were multiple changes in his journal. Moving the depokate, delaying the mirtazapine, and here you mentioned the melatonin decrease, as well as late-afternoon exercise. He also had a phone call late at night, which may or may not have been stimulating. 

 

I would go for a few weeks without any changes to his drugs and supplements and really work on getting to a stable baseline. There's no rush to get into a taper. In the long run, building up a stable baseline will go a long way to making his journey off these drugs a success.     

 

Since he's able to get out into the world and go to the gym, go swimming, etc. I would encourage him to join this site and become active in posting and asking questions. There are a number of young adults here who he likely has a lot in common with. 

 

Thanks for continuing to be his advocate.   

     

[Dshine]

Dear Shep, thank you so much for such an insightful analysis. BTW,  we did'nt change the melatonin dose the day when we moved the Depakote, only the day after.  But that doesn’t matter because you really remind me that we do chase the symptom  with the doses adjustment, which is not good to establish stability. I agree with you and we will keep that in mind to have Gogo’s med pattern unchanged for a while for the sake of Gogo’s sleep. Then we can start to tapering Resperidone. 

 

I  hope Gogo’s can join and be more open like other young adult, as well being more focused and get in-depth management to his meds.  It’s a graduate process. I’ll share the links with him and follow through. 

 

Thanks again, and will update. 

[Shep]

3 hours ago, Dshine said:

BTW,  we did'nt change the melatonin dose the day when we moved the Depakote, only the day after.  But that doesn’t matter because you really remind me that we do chase the symptom  with the doses adjustment, which is not good to establish stability. I agree with you and we will keep that in mind to have Gogo’s med pattern unchanged for a while for the sake of Gogo’s sleep. Then we can start to tapering Resperidone. 

 

Thanks for clarifying the melatonin information. Your insight about chasing the symptoms is spot on. Stability is key. Very glad to read Gogo will be holding everything steady until he stabilizes. 

 

3 hours ago, Dshine said:

I  hope Gogo’s can join and be more open like other young adult, as well being more focused and get in-depth management to his meds.  It’s a graduate process. I’ll share the links with him and follow through. 

 

 

Yes, this is a gradual process, but I hope for Gogo, one that is transformative. As we come off these drugs, we go through an un-patienting process. As we shed the drugs, we let go of the harmful labels and no longer define ourselves as patients in need of life-long drugging, but simply human beings who have emotions, just like anyone else. As Gogo learns new non-drug coping skills and is able to do more, he'll re-define himself as someone who is strong and capable of handling his emotions without these drugs. As this happens, he may wish to engage in conversations with his peers. But there's no rush. 

 

Please let us know how Gogo is doing over the coming days as he holds and stabilizes. 

[Dshine]

Yes, transformation, dear Shep, I couldn’t echo more with what you said. It’s great to see you put in this humane and beautiful way. Don’t we see a masterpiece without a dark color? Gogo will one day embrace this journal, out of which he will become stronger.   

 

Gogo is same like having more energy in the afternoon, he woke up one time in the middle of night that really annoy him. He need to  learn the coping skills to deal with that. Today the med is the same like yesterday, except there is delay of 1/2 hour for evening med due to some activities. Also  regarding supplements, do you think it's important to measure the portion in scale when you split the pill? 

 

Really appreciate this site and all the people who contribute here.

[Shep]

2 hours ago, Dshine said:

Also  regarding supplements, do you think it's important to measure the portion in scale when you split the pill? 

 

Gogo may not need to be as strict with weighing supplements as he is with psychiatric drugs. However, if he's very sensitive to things right now, it won't hurt to weigh them. By weighing supplements and keeping everything as consistent as possible, it removes one of the variables in withdrawal's very complicated equation. 

[Dshine]

5/15:

No fill of journal, bad mood waking up.   Saw Psy NP in the early morning, complaining his sleep, waking up etc. , and 3.75mg Remeron. Psy NP wanted to get off the Remeron and increase Resperidone for fewer meds. We decline that suggestion. Finally agreed to reinstate the original prescribing dose of 7.5mg Remeron to stabilize the sleep and to start Resperidone tapering when sleep is getting better. 

 

Is reinstating back to 7.5mg Mirt/Remeron a good choice? We agreed because we are not sure which dose of Mirt/Remeron is good for his sleep other than 7.5mg.  The Mirt/Remeron was tapered in a way of skipping doses directed by his PCP. 3.75mg worked for some night, but not all nights in the past month(waking up in the middle of night). Also we need to have suspension or liquid form of this med to get doses accurate. Need to ask his PCP next week.  

 

Afternoon, drove to shopping, seems good.  Afterward, sudden mood swing and anger, pacing,  accompanied by enuresis.  Not sure these symptoms especially enuresis are from the tapering of Mirt/Remeron or Depakote, or bed sleep, as he has been quite stable on Depakote tapering and holding 500mg for almost 2 month. His Valproic Acid level is below therapeutic level. Or it is because of the accidental CBD jacuzzi bath 10 day’s ago. Really frustrating didn’t realize this old Meg salt bought years ago from WholeFood market has CBD added and even some trace of THC until that night. He then heard voice in the middle of night, which caused him stay awake for almost rest of the night. Deep sleep is not as as good as before according to AW.  Not sure if these connect. 

 

Calming down a bit in the evening.  

 

Frustrated, and stressed,  refused to take the 9:30pm hypnotic med/supplement, ended up waking up around 2:20am, stayed up for an hour. 3:30am took only 7.5mg Mirg/Remeron without supplements. It seem 7.5mg worked and back to have another 6 hour sleep. 

 

5/16

Up 10am, mood better than yesterday. Took R, D and supplement (Mtv, Meg, B6 and fish oil)

 

After breakfast sleep another hour, working in the computer, reading, assembly a small desk. 

 

Afternoon Drove to shopping and feel good. 

 

Went to swimming for 30 minutes after dinner. 

 

5pm took Meg and fish oil 

 

7:30pm took R and D

 

Before bed time seems a little stressed but coping with meditation. 

 

9:30pm only 7.5mg Mirt/Remeron.  

 

10:30 bed time

 

Will see how is the sleep tonight, hopefully sleep through the night without waking up in the middle of the night. 

 

 

 

 

 

[Shep]

3 hours ago, Dshine said:

Saw Psy NP in the early morning, complaining his sleep, waking up etc. , and 3.75mg Remeron. Psy NP wanted to get off the Remeron and increase Resperidone for fewer meds. We decline that suggestion. Finally agreed to reinstate the original prescribing dose of 7.5mg Remeron to stabilize the sleep and to start Resperidone tapering when sleep is getting better. 

 

@Dshine We really need Gogo to stop making changes. His brain had already started adapting to the lower dose. 

 

You had noted earlier:

 

On 5/8/2023 at 8:13 PM, Dshine said:

I'm  reluctant to let my son go back to original dose of 7.5mg, which make him gaining so much weight and sleepy during the day.

 

 

On 5/11/2023 at 6:45 PM, Dshine said:

He think it’s the 3.75mg  Mirtazapine made him sleepy during the day, his PCP told him before that the lower dose of Mirtazapine have more sedated effect.  

 

 

Continuing to make changes will make it impossible for us to help Gogo. We don't know what dose of any of these drugs is doing what because he keeps making changes. It takes weeks or even months for the nervous system to settle down after each change.

 

Please note that increasing a sedating drug won't necessarily translate to better sleep. Please re-read the parts of this thread where we discussed paradoxical reactions caused by sedating drugs and supplements. 

 

Also, hypersensitivity and kindling are important to note when it comes to abrupt drug changes. Please see:

 

Hypersensitivity and Kindling

 

Again, holding for several weeks with NO CHANGES is the best thing Gogo can do right now. If he has a few weeks without much sleep, as long as he's otherwise healthy and doesn't have any other medical problems, he'll be fine. He can find some healthy distractions to take his mind off it, knowing that over the next couple of years as he comes off these drugs and heals, he'll have a fantastic drug-free life ahead. 

 

However, if he keeps rattling his nervous system by trying to temporarily fend off withdrawal symptoms, he's likely to kindle his nervous system. 

 

I would encourage you and Gogo to re-read this thread, including all of the links.

 

Also, it's best to do your research BEFORE Gogo makes changes. You can post your questions here and generally get a response within 24 hours. And we'll give you the best information we have based on the harm-reduction model of tapering that we advocate. And then you and Gogo can make your decisions based on this information. 

[Dshine]

16 hours ago, Shep said:

Also, hypersensitivity and kindling are important to note when it comes to abrupt drug changes. Please see:

 

Hypersensitivity and Kindling

 

Again, holding for several weeks with NO CHANGES is the best thing Gogo can do right now. If he has a few weeks without much sleep, as long as he's otherwise healthy and doesn't have any other medical problems, he'll be fine. He can find some healthy distractions to take his mind off it, knowing that over the next couple of years as he comes off these drugs and heals, he'll have a fantastic drug-free life ahead. 

 

However, if he keeps rattling his nervous system by trying to temporarily fend off withdrawal symptoms, he's likely to kindle his nervous system. 

 

I would encourage you and Gogo to re-read this thread, including all of the links.

 

Also, it's best to do your research BEFORE Gogo makes changes. You can post your questions here and generally get a response within 24 hours. And we'll give you the best information we have based on the harm-reduction model of tapering that we advocate. And then you and Gogo can make your decisions based on this information. 

Gogo read the link and he said he want to go back to 3.75mg. Do you think we got back to the same med/sup combination as  2 day’s ago?  Or just 3.75mg? 

Thanks a lot. 

[Shep]

5 hours ago, Dshine said:

Gogo read the link and he said he want to go back to 3.75mg. Do you think we got back to the same med/sup combination as  2 day’s ago?  Or just 3.75mg? 

Thanks a lot. 

 

I'm glad Gogo is wanting to go back to the 3.75 mg mirtazapine. 

 

I'm not sure I understand your question. Going back to 3.75 mg is okay. But what other changes were made? What changed from the "same med/sup combination as 2 day's ago" other than the mirtazapine increase? 

[Dshine]

8 hours ago, Shep said:

. But what other changes were made? What changed from the "same med/sup combination as 2 day's ago" other than the mirtazapine increase? 

Given other meds unchanged, here is the list for the evening hypnotic( med and supplements) check for the last few days: 

5/13 9:30pm  Meg/B6 50mg each,  melatonin 1.5mg and 3.75mg Remeron

5/14 9:30pm Meg/B6 50mg each,  melatonin 1.5mg and 3.75mg Remeron

5/15 9:30 Skipped, took 7.5mg Remeron at 3:30am

5/16 9:30pm 7.5mg Remeron

5/17 9:30pm 3.75mg Remeron,

         10:15pm to 2:30am sleep 

5/18 2:30am- 4am awake,  4am: 0.75mg Melatonin,  then fall back to sleep

5/18 10am woke up, took R & D and supplement

5/18 10:30am breakfast

5/18 11:30am sleep on sofa

 

As you can see here also in my previous post,  Gogo took 7.5mg Remeron for 2 nights (5/16, 5/17)  then yesterday back to 3.75mg. No other supplements yesterday, until 4am, he took 0.75mg Melatonin. I think he had a sound sleep after 4am to 10pm. 

[Shep]

14 hours ago, Dshine said:

As you can see here also in my previous post,  Gogo took 7.5mg Remeron for 2 nights (5/16, 5/17)  then yesterday back to 3.75mg. No other supplements yesterday, until 4am, he took 0.75mg Melatonin. I think he had a sound sleep after 4am to 10pm. 

 

Please convey the importance of not making any changes - no changes to the drugs, the doses, or the supplements. 

 

Once he keeps everything the same for a few weeks, it will be much easier to set up a taper plan. Hopefully his symptoms will ease off and he'll be able to tell how each of the drugs is affecting him without the confusion of if it's the *drug or supplement* or if it's the *drug or supplement change* that's causing the symptom. By not making any drug or supplement changes, it removes one of the variables. I  hope this makes sense. 

[Dshine]

Shep, it has been a while after the last post. I have been reading lots here recently.  Some updates: Gogo’s sleep I believe has improved after improved/less apnea with less waking up.  But he still sleep a lot and complain not having good sleep over the night and feel lethargic during the day. He usually feel better in the afternoon after a nap specially after taking the morning meds.  Most of day Gogo would feels like 7 out of 10. Only some occasional 8 out of 10 or 9 out of 10.  Excise including walking every day, swimming and hiking with friends. In July a psychiatrist from a  renowned hospital suggested mono-therapy because the psydoc don’t think Gogo needs to go to Bipolar clinic anymore. 

As for the tapering, and medication, we did have some changes.  We tried to reduce the Depakote by 125mg but failed since we don’t have the liquid form or springer.  Tapering Risperdon  started on Sept 26.

 

Risperidon:

9/26-10/5 1.85mg daily for 10 days (morning before 11am .85mg oral solution,  hard to get out of bed. 7:30pm:  1mg tablet,) accidentally got that .85mg due to fist time use of oral syringe.  keep that dose for 10 days.
10/5 daily dose reduced to 1.75mg, holding that dose now, don’t feel much difference from tapering.

 

Depakote:

Doses unchanged but move 125mg into the evening for sleep started on 9/24/2023

Before 11am 125mg (with Risperidon) , 9:30pm 375mg with 3.3mg mirtazapine. 

10/17/2015,  not taking  the morning dose of 125mg Depakote out of concern of “mildly” elevated ALT level (63) most likely caused by Depakote.

 

Continue take supplement.

 

Tapering of the Risperidon seems good without much wave and disrupting sleep. But the recent “mild”elevated ALT lab test really concerned us. Talked to NP  regard it but she seems Ok for Gogo to continue  taking the D. She agreed finally to prescribe the sprinkle capsule form of the Depakote for tapering purpose, and allowing us to go with our own pace of tapering. Hopefully it will get the insurance approval. Other wise we can’t cut the 125mg Delayed tablet.  But my Neurologists friend suggest to taper out of the Depakote in a month given Gogo’s ALT is in the trend of increase for the last 8 months.

 

May be go for micro tapering  Risperidon while waning the Depakote within a month?  How to cope with the possible sleep issue by Depakote’s fast tapering?  NP suggested to gradually add trazodone while mirtazapine is tapering slowly. We are actually micro tapering the mirtazapine. Introduce trazodone is a good  option  for coping with Depakote tapering to preserve the sleep too?

 

Thank you very much and appreciate the website and every one’s contribution! 

[Shep]

5 hours ago, Dshine said:

May be go for micro tapering  Risperidon while waning the Depakote within a month?

 

If Gogo has upticks in symptoms, will you know which taper is causing the problem? This is why we recommend tapering only one drug at a time. Please see:

 

The rule of 3KIS: Keep it simple. Keep it slow. Keep it stable.

 

Some people are able to taper multiple drugs, but it's not something we can help you with. This is only recommended for people who know their symptom pattern well enough to be able to sort it out themselves. 

Taper more than one drug at a time?
Try this only if you know your withdrawal symptom pattern and know how to control your taper with various tapering techniques.

 

5 hours ago, Dshine said:

How to cope with the possible sleep issue by Depakote’s fast tapering?  NP suggested to gradually add trazodone while mirtazapine is tapering slowly. We are actually micro tapering the mirtazapine. Introduce trazodone is a good  option  for coping with Depakote tapering to preserve the sleep too?

 

 

If Gogo needs to get off the Depakote, I would concentrate on that and stop tapering the Risperidon and the mirtazapine, especially if there's a medical reason that requires a faster taper off the Depakote. 

 

We don't recommend adding in more drugs to counteract the withdrawal of the current drugs. Trazodone is especially problematic. Please read the first post in this thread:

 

Tips for tapering off trazodone

 

For non-drug ways of dealing with sleep, please see:

 

Tips to help sleep: so many of us have that awful withdrawal insomnia

 

If mirtazapine is the most helpful for sleep, then the best thing to do is to taper it last. If there's a medical reason for coming off the Depakote, than I would concentrate on getting off that drug first, followed by the Risperidone, and then the mirtazapine.

 

5 hours ago, Dshine said:

Continue take supplement.

 

What supplement is he taking? 

 

[Dshine]

Thank you so much Shep for your timely reply. Gogo is doing fine. We just wait and see now but very hopeful. Will update soon. 

 

Regarding supplements, has been taking multiple VM, VD, fish oil, folic acid, ECEG, etc almost everyday. There are days not taking. 

[Shep]

5 hours ago, Dshine said:

Regarding supplements, has been taking multiple VM, VD, fish oil, folic acid, ECEG, etc almost everyday. There are days not taking. 

 

If Gogo is skipping days with the supplements, that can cause problems in the long run. It's best to take drugs and supplements at the same times of the day and at the same dose every day for best results.