From: "eliot gelwan" <eliot.gelwan@channel1.com>
Newsgroups: alt.psychoactives
Subject: pamelor part four
Date: 1 Oct 92 03:53:54 EST
Reply-To: "eliot gelwan" <eliot.gelwan@channel1.com>
Distribution: alt
Organization: Channel 1 Communications

How should the medication be taken? As with any medication, if your
physician's instructions are unclear, you should ask for
clarification. You and your prescribing doctor will individualize a tr
eatment plan for you.  However, some generalizations can be made.  The
medicatio n will be started at a low dose to make sure you can
tolerate it and to acclimat ize your body to its effects.  If you are
in good health, the dose will be incre ased every two to four days as
tolerated until it is in the therapeutic range. For the elderly or
infirm, the interval between dosage increases is lengthened, generally
to between seven and ten days as tolerated.  Your doctor should do a t
horough review with you of what side effects to anticipate.  For
example, knowin g of the risks of orthostatic hypotension may mean the
difference between becomi ng faint on arising, falling and injuring
yourself; and merely taking the care t o move slowly when standing up.

During this period of acclimatization to the medicine, it is important
for your psychiatrist to be available by phone or frequent follow-up
appointment to check on your progress, answer questions about the
effects you may be feeling, and re assure you.  Your comfort with the
medicine will be enhanced if you have a low t hreshold for contacting
your doctor if you are puzzled or troubled by anything y ou are
experiencing.

Generally, the medication is taken all at once at bedtime so that side
effects w ill peak overnight and so that sedation will be less
inconvenient.  If necessary , the dose can be divided into two or more
portions taken at different times of the day, where peak side effects
after a single dose have been intolerable.

The recipient should not expect to respond at once after starting on
an antidepr essant.  A one- to three-week interval to therapeutic
effect is the rule and a f our- to six- week lag is conceivable.
Unfortunately, there is no corresponding delay in the onset of adverse
reactions, so it may even be useful to anticipate feeling worse on the
medicine before you will feel better!  Where bearable, it i s
necessary to persist in the face of the discomfort of the side effects
(some o f which will attenuate) and of the lack of quick symptom
remission to give the m edicine a chance to be effective.
Furthermore, responsiveness to a particular a gent or a particular
dosage range is variable. While there are acknowledged "the rapeutic
dosage ranges" and some basis for individualizing choice of agent, an
e lement of trial and error prevails and you and your doctor may have
to make seve ral dosage increases or go on to a second or third
medication before an effectiv e regimen is found.

It should be stressed that the tricyclics must be taken regularly and
consistent ly to be beneficial.  They cannot be used on an "as-needed"
basis only on the da ys when you are feeling worst.  The need to
persevere with the medication during the two-to-four week lag time
until it takes effect must be borne in mind.

What if I don't respond? Because it takes some time for a tricyclic at
sufficient blood level to bring ab out the changes in the CNS that
cause resolution of target symptoms, a patient m ust have a trial of
adequate duration at effective dosage.  Even if you are taki ng the
recommended dose, poor absorption or rapid elimination of the
medication from your system may necessitate a higher dose, especially
if side effects are m inimal or being tolerated well.  Occasionally,
it will be useful to monitor the blood level of the medication, but
the inaccuracy in measuring such miniscule co ncentrations limits the
usefulness of the tests, and the range of effective bloo d levels has
not been meaningfully defined for all the agents in this class. As
mentioned above, when high doses of a tricyclic are employed, serial
EKGs should be followed as well.

After an adequate but ineffective trial, you and your doctor will make
a decisio n about switching to a different medication or attempting to
potentiate your cur rent medication with agents such as lithium
carbonate, thyroid hormone, or on oc casion the addition of a second
antidepressant.

Will I have to take the medication for the rest of my life? On the
basis of clinical experience and research, there is a consensus that
pati ents with major depression can typically be taken off their
antidepressant medic ation after six to eight months of clinical
response without doing worse than pa tients who continue on the
medication.  In contrast, premature discontinuation a fter fewer
months or after a less complete treatment response can often lead to a
relapse.  However, a patient who initially does well after
discontinuing an an tidepressant may have a recurrence months or years
later, as evidence suggests t hat up to 50% of patients who have had a
single major depressive episode will ha ve subsequent episodes. The
value of longer-term antidepressant maintenance to prevent recurrence,
as opposed to episodic treatment of any relapses, is uncerta in.

Much less evidence bears on the proper length of a course of tricyclic
therapy f or other conditions, either the attenuated (non-major)
depressive syndromes or t ricyclic-responsive non-depressive syndromes
such as panic disorder.  Often, pat ients with panic disorder require
open-ended treatment courses to avoid relapse, and
medication-responsive chronic depression or dysthymia may also relapse
if m edication is not maintained. Attempts to discontinue medication
should take pl ace in a measured way under regular ongoing followup
with a sensitivity to the c hance that resumption of medication use
will be merited.
     * * * C O N T I N U E D   T O   N E X T   M E S S A G E * * *
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EZ 1.39 #178 [in Brookline MA  7:56 pm, Wednesday 09/30/92]
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Channel 1 (R)   Cambridge, MA