644. Rebound mania following abrupt discontinuation of oxcarbazepine in bipolar I disorder: a case report

Abstract

Abstract Background Oxcarbazepine is commonly prescribed as a mood stabilizer in bipolar disorder, particularly for manic and mixed episodes. Abrupt discontinuation or rapid dose reduction of mood-stabilizing medications has been associated with rebound mania, defined as the rapid recurrence or worsening of manic symptoms following treatment cessation. While this phenomenon has been described with several mood stabilizers, rebound mania following oxcarbazepine discontinuation has not been previously reported in the literature. Aims & Objectives To describe a case of severe manic relapse with psychotic features following abrupt discontinuation of oxcarbazepine in a patient with bipolar I disorder, and to highlight the clinical implications of medication discontinuation in mood stabilization. Method This case report is based on a retrospective review of medical records and direct clinical observation during psychiatric hospitalization. Clinical information was obtained from patient interviews, chart documentation, and collateral reports from family members. The diagnosis of bipolar I disorder was established according to DSM-5 criteria. Symptom progression and treatment response were monitored throughout admission. The patient provided informed consent for the use of anonymized clinical data. Results A 48-year-old woman with a known history of bipolar I disorder presented to the emergency department with severe behavioral disturbance and excessive same-day lorazepam intake, which she denied was intentional. She reported physical and sexual abuse by her mother. Mental state examination revealed marked psychomotor agitation, irritability, disinhibition, hyperfamiliarity, pressured and coprolalic speech, flight of ideas, affective lability, and persecutory themes focused on alleged maternal aggression. The patient had been discharged seven days earlier following treatment for a mixed episode with psychotic features and was clinically stable at discharge. After discharge, she abruptly discontinued all prescribed psychotropic medications, including oxcarbazepine 1200 mg/day, followed by rapid clinical deterioration. Re-initiation of mood stabilizers and antipsychotics resulted in minimal improvement, with persistent severe manic and psychotic symptoms and lack of insight. Due to treatment resistance, electroconvulsive therapy (ECT) was initiated. Significant clinical improvement was observed after the first ECT session, and full symptomatic remission was achieved after 12 bitemporal ECT sessions administered three times weekly, without adverse effects. The patient was discharged on valproic acid, risperidone, levomepromazine, lorazepam, and scheduled maintenance ECT. Discussion & Conclusions This case illustrates a temporal association between abrupt oxcarbazepine discontinuation and the onset of severe rebound mania in a patient with bipolar I disorder. It emphasizes the need for careful tapering and close clinical monitoring when discontinuing mood stabilizers, even when evidence for rebound phenomena with a specific medication is limited. Clinicians should remain vigilant to the risk of rapid relapse following treatment cessation and consider proactive strategies to prevent severe mood destabilization.