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614-893-0910 or BTCarroll1@cs.com - 614-937-9427
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Social Anxiety Disorder
SAD has been the subject of increased research scrutiny in recent years. SAD is an early onset, chronic, frequently disabling disorder with lifetime reported prevalence rates around 13%.[2] SAD is characterized by a persistent fear of negative evaluation or scrutiny by others in social situations, resulting in excessive fear of humiliation or embarrassment, decrease in adaptive functioning, and clinical distress.[65] Patients with SAD are at high risk for comorbid disorders including other anxiety disorders, depression, and substance abuse problems. Both pharmacologic and cognitive-behavioral approaches to SAD are effective and offer complementary strengths.
The efficacy of irreversible MAOIs in the treatment of SAD is well established with several randomized, placebo-controlled trials.[67,68] For example, in a
study of 65 severe and chronic SAD patients, Gelernter and colleagues[69] found that phenelzine, cognitive-behavioral group therapy (CBGT), and alprazolam were superior to placebo (self-instructed exposure) in reducing SAD symptoms. Phenelzine conferred some advantage over alprazolam on measures of work and social disability. At week 12, 69% of the phenelzine group had responded compared with 38% of the alprazolam group, 24% of the CBGT group, and 20% of the placebo group. At the 2-month follow-up, following medication discontinuation, only the phenelzine and CBGT treatment groups maintained their treatment gains. These results are somewhat difficult to interpret since the study included one of the principal components of CBT, exposure, as a control group. In a 12-week treatment study, Heimberg and colleagues[70] examined phenelzine and CBGT vs a pill-placebo and psychotherapy control (educational supportive group therapy) in SAD patients. At end point, both phenelzine therapy and CBGT were associated with a significant positive response. Although phenelzine therapy was superior to CBGT on some measures, both treatment conditions were superior to the pill-placebo and psychotherapy control conditions. Responders to the acute trial entered a 6-month maintenance phase, and patients who continued to respond through the maintenance phase entered a 6-month treatment-free phase. In general, phenelzine patients entered the maintenance phase with greater improvements than did CBGT patients, and groups did not differ on relapse rates. Of note, phenelzine patients showed a trend toward greater relapse during the treatment-free follow-up. In a separate study, Liebowitz and colleagues[67] found that 64% of generalized SAD patients responded to phenelzine compared with 30% and 23% of patients treated with atenolol and placebo, respectively.
Despite phenelzine's efficacy in SAD, the dietary restrictions and risk of hypertensive crisis have reduced its acceptability as the favored first-line treatment for chronic SAD. The reversible MAOIs, such as moclobemide and brofaromine, have lower risk potential and fewer side effects than traditional MAOIs.
Controlled trials of moclobemide have yielded inconsistent findings over the past several years.[71-75] For example, in a double-blind, placebo-controlled comparison of phenelzine and moclobemide, both active treatments demonstrated clinical efficacy beyond placebo, and phenelzine was associated with significantly more adverse side effects than moclobemide. Relapse rates for both agents were quite high after discontinuation.[72] Large, multicenter, placebo-controlled studies of moclobemide have found minimal[73] to no efficacy.[71] Partial responders may benefit from SSRI augmentation with CBT,[90,95] buspirone,[110] benzodiazepines, gabapentin,[74] or venlafaxine.[113]
Treatment - Refractory Social Anxiety Disorder
TRSAD can be defined as those patients who do not respond to:
9) SSRI (1), SNRI (1), Buspar (1) or MAOI (1) trial(s) of an adequate dose or
duration 10) CGBT or Social Skills Training of an adequate duration 11) Have active alcohol or substance abuse, or are not candidates for CGBT or
Social Skills Training
Decreasing Side Effects to Increase Adherence
Robert Golden, MD,[126] Chair of the Department of Psychiatry, UNC School of Medicine, discussed the impact of drug-related side effects on patient compliance. SSRIs are safe and effective and have become the most widely prescribed antidepressants worldwide; however, several issues limit SSRI treatment outcomes. SSRIs have a favorable side effect profile when compared with earlier antidepressant agents, but even "minor" side effects can significantly affect treatment outcome by interfering with patient compliance. Approximately 33% of patients stop taking their prescribed medication within the first month; nonadherence increases to 56% after 4 months of treatment.[127] Adherence may be increased with increased patient and family education, careful and sensitive inquiry and monitoring over the cause of treatment-related side effects, and selection of medications based on expected side effects (including an understanding of
pharmacodynamic and pharmacokinetic profile). Nausea is one of the most common and early-occurring SSRI side effects. Nausea is reported in 20% to 25% of patients on SSRIs.[128] Over time, gastrointestinal (GI) side effects typically wane; however, this time-lag carries a burden in terms of treatment outcome. For example, GI effects are associated with medication noncompliance, which is associated with delaying the time to attain a full therapeutic dose, or resulting in the failure to reach that desired dose
due to early treatment discontinuation. SSRIs are initially absorbed in the upper small intestine. The drug stimulates serotonin receptors in the submucosal plexus, which is associated with orchestrated peristalsis. When the SSRI is present, serotonin floods the receptors and causes overstimulated contractions. Recent delivery advances (eg, a controlled-release formulation of paroxetine) can diminish these effects. Specifically, the active SSRI is an enteric-coated formula that is absorbed in a more distal region of the small intestine, thus avoiding the stimulation of gastrointestinal 5-HT receptors that mediate nausea. Recent studies have demonstrated that Paxil-CR is associated with fewer
dropout rates due to side effects than the original formulation of Paxil.[129] Sexual side effects are also associated with decreased compliance in SSRI maintenance treatment. Approximately 15% to 50% of individuals will report some sexual side effect with SSRI therapy. According to Dr. Golden, several strategies may be employed to decrease these undesired effects. • Consider using an antidepressant that is not associated with sexual side effects.
• Switch to a different antidepressant if symptoms emerge
• Add adjunctive medications to counteract side effects (eg, sildenafil for erectile dysfunction, bupropion for decreased libido or ejaculatory problems).
• Adjust dose and dosing schedule.
• Allow drug holiday in anticipation of sexual activity (if clinically warranted; some reports suggest an increase of relapse even with shorter drug holidays).
According to Dr. Golden, future research should focus on making advances where it matters; specifically, using medical knowledge to decrease side effects
that may sabotage patient treatment compliance.
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Panic Disorder
Panic disorder is a commonly occurring, chronic, often unremitting anxiety disorder that can be associated with extreme impairment and disability. The core symptoms of panic disorder are recurrent and often unexpected; panic attacks are often coupled with anticipatory anxiety and phobic avoidance, which together impair the patient's professional, social, and familial functioning. Research into the optimal treatment of this disorder has been undertaken in the past 2 decades, and numerous randomized, controlled trials have been published.
Selective serotonin reuptake inhibitors (SSRIs) have emerged as the most favorable treatment due to their safe and tolerable side-effect profile. High-potency
benzodiazepines, monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants (TCAs), and cognitive-behavioral therapy (CBT) are efficacious in the
acute and long-term treatment of panic disorder.[5,6] In recent years, however, there has been a "certain neglect" of pharmacologic advances for panic disorder, perhaps due to a perceived, or misperceived, notion that the current pharmacologic agents are effective. Long-term efficacy data suggest that acute treatment benefits often fail to endure over time, and relapse rates are high. Starcevic stated that there is "significant room for
improvement" in the management of panic disorder. Both pharmacologic and cognitive-behavioral treatments suggest clinical efficacy in panic disorder,[5,6] yet the relative advantages and disadvantages of each are debated between the two camps.
"Perceived" advantages of pharmacologic interventions vs CBT:
• "Faster" therapeutic onset (especially with
benzodiazepines);
• More reliable prevention/elimination of panic attacks
and decreased anxiety;
• More likely prevention and/or treatment of psychiatric
complications and secondary psychopathology such as
major depressive disorder;
• Easier to comply with treatment protocol;
• More widely available, easier to administer, and lower
cost.
"Perceived" disadvantages of pharmacologic interventions
vs CBT:
• Less effective in decreasing agoraphobic avoidance;
• Associated with side effects, which are at times intolerable;
• Failure to promote active coping, and encouragement of
excessive reliance on medications;
• May be associated with dependence (psychological and/or
physiological);
• Less able to affect vulnerability to relapse, and
associated with increased relapse upon treatment
cessation.
Pharmacologic Improvement Strategies. To date, there has been equivocal evidence of increased treatment efficacy, long-term outcome, treatment compliance, and faster response with add-on medications. There is, however, good evidence that dependence-related problems have decreased, particularly since treatment no longer relies on short-acting benzodiazepines for longer-term treatment.[8,9]
Antidepressants (TCAs, SSRIs) and benzodiazepines were the first effective treatments for panic disorder and remain valuable tools in the management of panic and other anxiety disorders. There are publications supporting the efficacy of all SSRIs in the treatment of panic disorder,[10] and the US Food and Drug Administration (FDA) has approved paroxetine and sertraline for panic treatment. Meta-analyses suggest that both high-potency benzodiazepines and antidepressants are effective in reducing panic attacks, achieving a panic-free state, and improving anxiety, agoraphobic avoidance, and overall functional impairment.[11-13] Antidepressants may hold a distinct advantage over benzodiazepines in their ability to reduce depressive symptoms. Drawbacks exist for each drug class. Benzodiazepines are associated with sedation, interdose anxiety, and rebound symptoms upon discontinuation; TCAs provoke undesirable anticholinergic
effects, which may be particularly troublesome for panic patients; and SSRIs have a slow therapeutic onset and may cause sexual side effects or hyperstimulation. Maximizing the strengths and minimizing the weaknesses of these agents can result in a successful combination treatment. New pharmacologic approaches for panic have been examined in pursuit of enhanced efficacy, response, and tolerability. Results thus far have provided neither consistent nor convincing evidence that the new medications are more effective; however, some agents may have an earlier onset of efficacy (eg, escitalopram, mirtazapine) and better tolerability (eg, escitalopram, nefazodone, mirtazapine).[17-22]
Pharmacologic Improvement Strategies
CBT has demonstrated efficacy as a treatment for panic disorder.[32]
Pharmacologic agents have also been successfully combined with CBT and may offer distinct treatment advantages. Evidence suggests that pharmacotherapies may be most
effective against unexpected panic attacks, and therefore more so in the treatment of panic disorder without agoraphobia. Furthermore, cognitive-behavioral tools and exposure-based practice may enhance pharmacotherapeutic outcomes in the long-term and facilitate relapse prevention efforts.
In one study, Barlow and colleagues[33] conducted a methodologically rigorous randomized, double-blind, placebo-controlled study examining the efficacies
of CBT, imipramine, or their combination in the acute (3-month) and maintenance (6-month) treatment of 312 patients with panic disorder. Both imipramine and
CBT were significantly superior to placebo in the acute treatment phase, as measured by improvement on the Panic Disorder Severity Scale (PDSS); however, this advantage did not hold up on the Clinical Global Impressions Scale (CGI).
After 6 months of maintenance treatment, imipramine and CBT were more effective than placebo on both primary outcome measures. The acute response rate for the combined treatment was 60.3% for the PDSS and 64.1% for the CGI. CBT plus imipramine did not differ significantly from the other treatment groups. The 6-month response rates for CBT plus imipramine were greater than CBT alone and imipramine alone on the PDSS, and greater than imipramine alone on the CGI. Of note, CBT plus imipramine did not confer a unique advantage over CBT plus placebo. At 6-month follow-up, patients receiving CBT plus imipramine were more likely to relapse than those receiving CBT plus placebo or CBT alone. Though the implications of this finding are somewhat unclear, the authors concluded that the combination of CBT plus imipramine may confer limited advantage in the acute management of panic disorder and more substantial advantage by the end of maintenance therapy. Each treatment worked well immediately following treatment
and during maintenance, and CBT appeared particularly robust at follow-up.
Treatment - Refractory Panic Disorder
TRPD can be defined as those patient who do not respond to:
1) SSRI (1), SNRI (1) or TCA (1) trial(s) of an adequate
dose or duration
2) CBT of an adequate duration
3) High -potentcy BZD
4) Have substance abuse, or are not candidates for CBT
One option for these patient is to consider second line agents such as anticonvulsants or antipsychotics. Novel agents may offer distinct advantages, but until their efficacy profiles are better established, their status should still be considered experimental. Treatments combining pharmacologic and/or cognitive-behavioral techniques may be useful in increasing long-term outcome and decreasing risk of relapse upon treatment cessation.
Recent Advances in Generalized Anxiety Disorder
Sigfried Kasper, MD,[36] from the University of Vienna, Austria, described GAD as a "poorly understood disorder," and highlighted the recent upsurge in attention to its diagnosis and treatment. The diagnostic criteria of GAD have continuously evolved over the past 2 decades, making consistent research efforts difficult. Despite these changes, clinicians and researchers generally agree that the principal targets of intervention in GAD are persistent and uncontrollable worry, psychological anxiety, and somatic symptoms (eg, physical tension, difficulty concentrating). The symptoms of GAD are excessive and endure for most of the day nearly every day for a minimum of 6 months. Prevalence rates of GAD range from 1.5% to 3% for current GAD, 3% to 5% for GAD in the past 12 months, and 4% to 8% for lifetime GAD.[37] Many more individuals experience subsyndromal forms of GAD. GAD is highly comorbid; lifetime and current comorbidity estimates are 89.9% and 65%, respectively.[38-40] Studies suggest that approximately 38.6% patients with GAD also meet criteria for major depressive disorder,[40] the latter of which often drives professional help-seeking. According to Dr. Kasper, GAD patients frequently attend treatment, though treatment is often inadequate. Effective treatment of GAD should strive to attain a strong therapeutic alliance, reduce acute symptoms, resolve persistent and chronic anxiety, and prevent relapse. Optimal treatments may incorporate pharmacotherapy and psychotherapy for long-term symptom management. Treatment options for GAD are many and include empathic listening, applied relaxation, CBT, benzodiazepines, serotonin-1A (5-HT1a) partial agonists,
antidepressants (ie, SSRIs, SNRIs), and newer compounds such as pregabalin. Historically, GAD was treated with benzodiazepines, which offer a good low-cost anxiolytic effect in the short-term. Several randomized, controlled trials of benzodiazepines have demonstrated acute clinical efficacy in reducing GAD symptom severity. The long-term efficacy of benzodiazepines is less robust.[41-43] The primary anxiolytic effect of the benzodiazepines addresses the somatic symptoms of GAD but leaves the cognitive features of GAD such as worry and psychological distress somewhat unresolved. Furthermore, benzodiazepines do not appear to be efficacious in reducing the depressive symptoms common in GAD. Because of the risk for physical dependence, rebound anxiety upon discontinuation, and side effects, benzodiazepines are now a secondary treatment option or an acute adjunct to long-term treatment with other agents. In general, 5-HT1a partial agonists have proven substandard in the treatment
of GAD, with the exception of the azapirone buspirone. Early trials of buspirone suggested it was an efficacious alternative to benzodiazepines for treating anxiety, with some specificity for the psychological symptoms of GAD.[44-46] However, recent studies are more equivocal about buspirone's efficacy in GAD[47,48] and the symptoms of its common comorbid conditions.[41] More recently, antidepressants have secured a primary role in the pharmacopoeia of GAD. Data suggest that TCAs are equally as effective, if not more effective, as benzodiazepines in treating GAD, and imiprimane consistently produces higher improvement rates than placebo.[41] The anticholinergic effect of TCAs may exacerbate anxiety in patients who are already disposed to somatic symptoms. Rickels and colleagues[49] conducted a randomized, double-blind, 8-week comparative trial of imipramine (mean maximum daily dose, 143 mg), trazodone (255 mg), and diazepam (26 mg) in 230 patients with GAD. Patients with comorbid panic disorder or depression were excluded. All active treatments were more effective than placebo at reducing GAD symptoms. The greatest number of patients responded to imipramine (73%), followed by trazodone (69%), diazepam (66%), and placebo (47%). Patients treated with diazepam showed the most improvement in anxiety ratings during the initial weeks of treatment, with enhanced efficacy for somatic symptoms. However, imipramine achieved better anxiolytic efficacy in the latter weeks of treatment. Trazodone was comparable with diazepam. Imipramine was most effective for psychic symptoms of tension, apprehension, and worry, and all 3 treatments reduced somatic symptoms. Overall, patients treated with antidepressants reported a higher rate of adverse effects than diazepam-treated patients, but discontinuation rates did not differ by treatment group. There is a growing body of literature demonstrating the efficacy of SSRIs in placebo-controlled studies of GAD.[50-53] While the majority of these reports
have studied paroxetine,[52] which is now approved by the FDA for the treatment of GAD, positive findings with fluvoxamine and sertraline are also published.[41-43] A pooled analysis of 3 positive, double-blind, placebo-controlled studies in 856 patients with GAD found that escitalopram has effective anxiolytic properties in this population.[53] The SNRIs such as venlafaxine have also demonstrated efficacy in reducing GAD symptoms; venlafaxine is the first agent indicated for the long-term
treatment of GAD. Several placebo-controlled studies have indicated that venlafaxine-XR is effective in reducing the somatic and psychic symptoms of anxiety specific to GAD both in acute[54-56] and long-term treatment.[57-59] For example, Davidson and colleagues[55] found that venlafaxine-XR was associated with a greater reduction in Hamilton Anxiety Rating Scale scores than both buspirone and placebo. Taken as a whole, these studies suggest a rapid onset of action, greater tolerability than TCAs, and relapse prevention efficacy for at least 6 months with
w venlafaxine-XR administration.
Psychotherapeutic tools that help patients develop coping and cognitive-restructuring strategies to manage their symptoms of anxiety are also efficacious in the integrated treatment of GAD. The most extensively studied psychotherapy for GAD is CBT, which targets the intolerance of uncertainty and the perceived uncontrollability or danger associated with worry. CBT has demonstrated efficacy as a short-term and long-term treatment option in GAD and is associated with low relapse rates.[42]
In an interesting study, Fisher and Durham[64] conducted a reanalysis of 6 randomized, controlled trials of psychological therapy with GAD. Individual CBT and applied relaxation, focusing on excessive worry and physiological arousal, performed well, with overall recovery rates of 50% to 60% at 6-month follow-up. In general, GAD patients are responsive to treatment; however, they are also sensitive to medication side effects. Combined pharmacotherapy (eg, benzodiazepines plus SSRIs) or pharmacotherapy plus CBT may be appropriate for treatment-resistant patients.
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By Jannsen-Claig
Panic attacks and panic disorder
People with panic disorder suffer unexpected and repeated episodes of intense, overwhelming terror for no apparent reason (panic attacks). Their fear may be accompanied by physical symptoms such as chest pain, heart palpitations, sweating, hot or cold flushes, trembling, dizziness, choking or smothering sensations and shortness of breath. Some people feel like they are being devoured by fear, or going crazy.
Panic attacks typically occur spontaneously, with no apparent trigger. They can occur at any time, even during sleep, and because they can not predict when a panic attack will seize them, many people live with the persistent worry that another attack could overcome them at any minute.
Most panic attacks last only a few minutes, but they occasionally go on for 10 minutes and, in rare cases, have been known to last for as long as an hour. However, they often feel like an eternity for the patient.
The symptoms of such panic attacks often mimic symptoms of a heart attack or other life-threatening medical conditions. Often, people suffering a panic attack may rush to hospital, convinced they are having a heart attack, or suffering from a respiratory problem, neurological disorder, or gastrointestinal condition. They may also fear that they are losing control or becoming psychotic. As a result, it is common for people with panic disorder to see as many as 10 different doctors, undergo many unnecessary tests, and suffer for years before obtaining a correct diagnosis. The diagnosis of panic disorder is frequently not made until extensive and costly medical procedures fail to provide a correct diagnosis or relief.
Many people with panic disorder develop intense anxiety between episodes. It is not unusual for a person with panic disorder to develop phobias about places or situations where panic attacks have occurred, such as in supermarkets or other everyday situations. As the frequency of panic attacks increases, the person may begin to avoid situations where they fear another attack might happen or where help would not be easily available. This avoidance may eventually develop into agoraphobia, an inability to go beyond known and safe surroundings because of intense fear and anxiety.
When a person has repeated panic attacks, and feels severe anxiety about having another attack, he or she can be diagnosed as having panic disorder. Panic disorder tends to worsen over time if it is not treated successfully.
About 2% of adults suffer from panic disorder in a given year.
Women are twice as likely as men to develop panic disorder.
Panic disorder typically strikes in young adulthood. A half of all people who have panic disorder develop the condition before the age of 24.
Panic disorder can coexist with other disorders, most often depression and substance abuse. About 30% of people with panic disorder abuse alcohol and 17% abuse drugs, such as cocaine and marijuana, in unsuccessful attempts to reduce the distress caused by their condition. Appropriate diagnosis and treatment of other disorders such as substance abuse or depression are important to successfully treat panic disorder.
The exact causes of panic disorder are unknown, but heredity and stressful life events may each be important. There may also be , and thinking in a way that exaggerates relatively normal bodily reactions are all believed to influence the onset of panic disorder.
The importance of treatment
Repeated panic attacks can have a devastating impact on people. Without treatment, the attacks, or the person's attempts to avoid them, can completely take control of a person's life.
Without treatment, sufferers may continue to have panic attacks for years. This can seriously interfere with their relationships with family, friends, and co-workers.
Life may become severely restricted. For example, the person may start to avoid situations in which they fear that they will experience a panic attack. This could include normal, everyday activities, such as shopping for food, or even driving. In extreme cases, people with untreated panic disorder become afraid to leave their house: a condition known as agoraphobia.
Some people may find it difficult to be productive at work. The symptoms may keep them from travelling to their job, or feeling able to stay there once they arrive. They may turn down promotions or job assignments which they believe will make them more likely to have panic attacks. Some people with panic disorder even resign from their jobs. Some who keep working only rarely leave home for any reason other than work.
Many people become severely depressed. They may try unsuccessfully to reduce the symptoms of panic disorder or depression with alcohol or other drugs. They may even begin to have thoughts about suicide.
Treatment for panic disorder
Treatment for panic disorder can consist of taking a drug to normalise levels of brain chemicals, just as you might take medicine to correct a thyroid imbalance. In addition, treatment might involve working with a psychotherapist to gain more control over your anxieties, just as some people work with specialists to learn techniques to control migraine headaches or lower their blood pressure. The type of psychotherapy which is used is known as cognitive-behavioural therapy (CBT), which teaches people how to view panic attacks differently, and demonstrates ways to reduce anxiety. Both medication and psychotherapy can be very effective. For many patients, a combination of medication and psychotherapy can be even more effective than either treatment alone. Appropriate treatment by an experienced professional can reduce or prevent panic attacks in 70 to 90% of people with panic disorder, usually within 6 to 8 weeks.
Most patients show significant progress after a few weeks of therapy (but in some people, treatment may take longer to produce a noticeable effect). Relapses may occur, but they can often be treated effectively. Early treatment can help keep panic disorder from progressing. However, only about one in three people with panic disorder receives appropriate treatment.
Cognitive-Behavioural Therapy (CBT)
Cognitive-behavioural therapy (CBT) teaches people to anticipate and prepare themselves for the situations and bodily sensations that may trigger panic attacks. CBT usually includes the following elements:
The therapist helps the person identify the thinking patterns that lead them to misinterpret sensations and assume the worst is happening. These patterns of thinking are deeply ingrained, and it will take practice to notice them and then to change them.
The therapist can teach the person breathing exercises that calm them and that can prevent the hyperventilation (excessively rapid breathing) that often occurs during a panic attack.
The therapist can help the person gradually become less sensitive to the frightening bodily sensations and feelings of terror. This is done by helping the person to gradually and safely test themselves in the places and situations they have been avoiding.
To be successful, CBT requires the patient to be motivated and the therapist to be specially trained. CBT generally requires at least 8 to 12 weeks to produce an effect, but some people may need more time in treatment to learn the skills and put them into practice. Most panic disorder patients are successful in controlling or preventing their panic attacks after completing treatment with CBT.
Medication
Several types of medication that alter the ways chemicals interact in the brain can reduce or prevent panic attacks and decrease anxiety. Both antidepressants and benzodiazepines have been shown to effective in the treatment of panic disorder and generally well-tolerated by patients.
Each medication works differently. Some work quickly and others more gradually. All have to be taken on a regular basis. Usually, treatment with medication lasts at least 6 months to a year, but after about 8 weeks, the sufferer and their doctor should be able to assess whether the treatment is reducing the panic attacks.
For many patients with panic disorder, a combination of CBT and medication may be the most successful approach.
Achieving treatment success
From the beginning, it is important to for the patient to be fully informed about the treatment, to ask questions and to voice their concerns. Every patient responds differently, but it is important to know that no treatment for panic disorder works instantly, so it is important to persist with a particular treatment for at least 6 to 8 weeks to see if it works. If improvement is not seen within that time, the treatment plan can be adjusted. It may be a matter of trial and error before the best treatment is found, so patience is essential.
If the treatment involves medication, it should be clear how often and in what manner the dosage will be monitored. No matter what medication is being used, the doctor is likely to begin with a low dose and gradually increase it to the full dose. Every medication has side effects, but they usually become tolerated or diminish with time. If side effects become a problem, the doctor may suggest stopping the medication waiting a week or so before trying another medication. When the treatment is near an end, the doctor will reduce the dosage gradually.
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