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Brief Answer:
It is best to start withdrawal after you settle the work situation, being under stress will not help you successfully withdraw from Rivotril (clonazepam)

Detailed Answer:
Hello and welcome to "Ask a Doctor" service,

I checked all the medications you have used. All of them are antidepressants that may help with anxiety but are not recommended in bipolar disorder. Taking antidepressants when having bipolar disorder may make bipolar disorder worse. This may be the reason you do not feel better with them.

Are you able to access quetiapine? This is a drug that helps with depression and anxiety and that is also used to control the mood in bipolar disorder. So, it is the best drug in your case. When you are under the effect of quetiapine you may also add one of the above antidepressants but only after some time after starting quetiapine.

As for withdrawing clonazepam, I understand that it is best to put things in order before you try to withdraw. If there are stressors around that are pressing on you, the process of withdrawing clonazepam may be very difficult, unsuccessful and you may also be having problems with work/ family due to withdrawal symptoms.

I need you to clarify if you use now a daily dose of clonazepam of 2 mg or you use 2 mg several times a day. It is very important to know the total daily dose (if you use 2 mg in the morning and 2 mg in the evening then this is 4 mg a day). Please confirm which is the total daily dose you use, if it is 2 mg or more.

A stepwise approach would be:

1. first take quetiapine (it is started at 50 mg at night, the next day it is taken 100 mg at night, on day 3 it is taken 200 mg at night and then it is continued at 300 mg at night every day for better control of bipolar disorder).
This will help with bipolar disorder, anxiety, and depression.

2. later, 2-3 weeks after starting quetiapine, an antidepressant (citalopram for instance) can be started (if quetiapine is not helping enough).

3. you will need to decide a proper time to withdraw from clonazepam. We recommend patients to decide a date in the future when they think they may be ready. I think you need to put the things at work in order first, take the above treatment (quetiapine +/- citalopram) and consider revisiting the idea of withdrawing from clonazepam in 2 months.
- I would not go too long (if possible) because the longer you use clonazepam, the more difficult it will be to withdraw. But a good balance is needed (not to withdraw too early or too late).

4. In 2 or 3 months, if you feel better with quetiapine and citalopram and the work situation is settled you may try to start to withdraw clonazepam (you may decide to do this later if things do not seem well).
- to make the withdrawal easier, I would probably consider a slower withdraw than the scheme I gave you previously. For instance, if you decide to start withdrawing on December 20th than:

take 1.75 mg of clonazepam each day from December 20th to January 5th
1.5 mg of clonazepam each day from January 6th to January 31st
1.25 mg of clonazepam each day from February 1st to February 15th
1 mg of clonazepam each day from February 16th to March 1st
0.75 mg of clonazepam each day from March 2 to March 15th
0.5 mg of clonazepam each day from March 16th to March 31st
0.25 mg of clonazepam each day from April 1st to April 15th
Use no clonazepam from April 16th and on

You will need to continue quetiapine (and citalopram if you started it) during the time you are going to be withdrawing from clonazepam, and a few months after. This will help with better control of anxiety.

I tried to be thorough and clear but please let me know if there is anything unclear. Also, let me know if you use more than 2 mg of clonazepam (Rivotril) a day.

Finally, I need to stress the importance of being followed up with a doctor while taking these steps to withdraw from Rivotril. It is crucial for a successful withdrawal and for your safety.


I hope this answers your query.
I remain at your disposal in case further medical assistance is needed.

Regards,
Dr. Antoneta Zotaj
General and Family Physician

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