Diagnosis & Management
Strategy For AntiDepressant Medications
Here are a few rules for use of AntiDepressants. They are determined by the biological half-life of the medications, by their effective dose and by the usual duration of Depression after treatment has begun.
The First Few Weeks Of Treatment
It is important to remember the delay between improved behavior and improved thought. The family is the first to know when the dose is right. They are the only accurate barometer of future blue skies or storm clouds.
Conversely, when the MSer stops the pills, family notices immediately, the return of depressed voice and posture. These changes often occur before the MSer notices the return of depressed thoughts.
Strategy For Stopping Treatment
Plan with your family for your future use of AntiDepressants. Most people need AntiDepressant medication for 6 to 15 months, and can then stop without immediate return of Depression.
Knowing the usual duration of treatment, the MSer can agree to stay on the AntiDepressant dose for at least six months. After that time the MSer will begin to reduce the dose by one increment each month.
If Depression still does not return, the MSer can continue to reduce the medication monthly over a period of several months. Most people begin to decrease the dose before their Depression is over so it returns.
Standard TriCyclic AntiDepressantsChemical Trade Therapeu- Increase Onset Of Wait Time Name Name tic Dose Amt Action For Increase ________________________________________________________________________ Imipramine Tofranil 75-300mg 25mg 7-14 days 2-3 wks Imavate Amitriptyline Elavil 75-200mg 25mg 7-14 days 2-3 wks Desipramine Norpramin 30-250mg 25mg 7-10 days 2-3 wks Pertofrane Doxepin Adapin 75-250mg 25mg 14-21 days 4 wks Sinequan Nortriptyline Aventyl 50-100mg 25mg 14-21 days 2-3 wks Protriptyline Vivactil 15- 60mg 5-10mg 7-14 days 2-3 wks ________________________________________________________________________ Newer AntiDepressantsMaprotiline Ludiomil 75-200mg 25mg 3-21 days 2-3 wks Amoxapine Asendin 100-300mg 50mg 4-21 days 2-3 wks Trazodone Desyrel 100-400mg 50g 4-21 days 2-3 wks ________________________________________________________________________
The standard group of AntiDepressants are TriCyclic compounds with similar chemical structures. The newer AntiDepressants are chemically diverse.
The possibility of a more rapid onset of action is an advantage, but all of them have delayed onset action in some people.
So the waiting time between dosage increments is unchanged to guard against too rapid increase of dose among persons whose response will appear, but not at the accelerated time.
Usually, depressed people do not accept first barometric reports that storm clouds loom on the horizon. After all, a temper tantrum may have occurred before depressed thoughts developed.
An emotional outburst that sounds inappropriately violent to the family may not seem so to the person coming off medications. The job of the family isn't to force the MSer back on pills but to inform.
Depressed people are not crazy. They are able to reason and think clearly, especially if they get feedback early in a depressed period.
If family members have made an accurate diagnosis, the return of depressed thoughts, reappearance of weeping spells and temper tantrums convince most depressed people that the medication is needed.
Once you make the decision, return to the proper dose, the same as it was before. Continue it for another four to six months and then try again.
Most Msers can finally stop treatment. Some stop periodically and go back again in six months or a year. Some must take Elavil for many years.
If a medication makes life worth living, why not take it? AntiDepressants are relatively safe for long term use, and are preferable to the disruptions caused by Depression.
Cautions About The Use Of AntiDepressants
Serious side effects are unusual, and the benefits of treatments are impressive. Most MSwes appreciate Elavil or a related compound despite irritations like dry mouth and some sedation.
Some MSers should investigate more serious complications, and talk with their doctor before they accept treatment. Glaucoma may flare up, causing pain and visual loss in one or both eyes.
This complaint could be mistaken for Optic Neuritis! MSers with Glaucoma must have their ocular pressures monitored as they use AntiDepressants.
MSers on AntiDepressants who develop new visual complaints, should remind the doctor of this possible complication and ask for prompt referral for Glaucoma testing.
Seizure disorder may become more difficult to control. Blood AntiConvulsant levels should be checked before starting treatment and again soon afterwards, to be certain they do not change.
Kidney and Liver Disease may also be aggravated by AntiDepressants. If you have Heart failure, Angina, disturbances of Heart rhythm or have had a recent Heart Attack, speak to your doctor first.
These complications are serious contraindications to the use of AntiDepressants. Perhaps ask for help from a Psychiatrist with experience in the use of these medications. Then decide if your Depression warrents the risk.
Emotional Incontinence Is Not Depression
Some MSers and many other Neurological patients have frequent brief episodes that are easily mistaken for Depression.
If someone unexpectedly walks into the room, if a brief sad remark is made, if the person laughs, a weeping spell may appear suddenly and without warning.
Indeed laughter may change directly into a silent wail that resembles the worst of grief. The spells are brief, usually less than half a minute.
Often there are no tears. There is no accompanying sad emotion. Crying just happens. People are never violent during these attacks, and between spells, emotional tone is normal.
This is called "PseudoBulbar Emotionality" or "Emotional Incontinence", (Emotional Lability).
It occurs most commonly in people who have had bilateral Stroke, but it can occur in anyone with lesions of any kind on both sides of the Brain. I think of it as an accentuation of normal emotional responsiveness.
When I listen to Puccini, for instance, I am not depressed. But his heartrending melodies always bring a catch to my breath and a lump to my throat that lasts throughout the performance.
After I have had a Stroke or whatever, connections from my thinking Brain to my feeling Brain will be weakened and I won't be able to control my emotions as easily as I do now.
Other people will see my Emotional Incontinence for the first time. I have been embarrassed by that response for years. The difference is, it never used to show.
Emotional Incontinence Is Often Treatable
Emotional Incontinence is sometimes controlled by Levodopa, a medication with powerful effects on Nerve Cells deep in the Brain. Levodopa is usually used against Parkinson's Disease.
Its effect on Emotional Incontinence was first noticed when emotional outbursts stopped for some Parkinson patients, even before there was improvement in their Parkinson symptoms. A recent report has confirmed those original observations.
If the description of easy laughter or crying in this section describes your situation, talk with your doctor about the use of Levodopa.
Begin with a small dose, 250mg three or four times per day, and increase the dose slowly at four to five day intervals to a maximum of 2000mg per day.
If your easy laughter or crying does not stop on 2000mg per day of Levodopa, it is ineffective for you and should be stopped.
Levodopa may cause nausea and sometimes vomiting. This can usually be controlled by taking it after meals or a snack.