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Re: Dose increase recommendations vs time for effect?

Posted by linkadge on December 26, 2020, at 13:44:50

In reply to Dose increase recommendations vs time for effect?, posted by Mtom on December 26, 2020, at 12:07:37

Interesting conversation ...

I often wonder these things myself. I also wonder these things in the context of 'rapid acting' antidepressants.

A therapist once told me ... "You didn't become depressed overnight, so don't expect to get better overnight". I have heard variations of this many times over the years. But the question is whether or not it's true.

The notion that the brain needs time to 'heal' is likely true to an extent. However, things like ketamine, sleep deprivation, ECT can work very quickly.

It is difficult to say why the time / dose course can vary from person to person. With standard antidepressants, some people feel better in a week, while others need weeks or months. In studies I have read, mirtazapine does appear to work relatively rapidly, but (as you mention) different doses can have different effects.

I think in many cases, the highest *tolerated* dose is probably best (at least, for severe depression). Some of the adaptive changes probably happen quicker at a higher dose. But you also need to consider other factors like side effects. If the patient is overwhelmed by side effects, they may not wait for a response. Conversely, if they have to wait too long, they may also not respond. As you mention too, not all antidepressants have a linear dose/response relationship. Or (depending on the patient) higher doses may start to be counterproductive. For example, effexor becomes more noradrenergic at higher doses. This may help some patients but make others worse.

You kind of have to play around with different doses yourself and then be assertive with your doctor. I know (in the old days) recommendations for nardil were to initiate with a high dose (until remission) and then lower down to a maintenance dose (i.e. 15-30mg).





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