Brief Answer:
Wait for the response with raised dose

Detailed Answer:
Hello
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FDA recommends SSRI as first line drug which raises level of serotonin in brain. Duloxetine and Desvenlafaxine are SNRI that raises levels of serotonin and Norepinephrine both. These are recommended as second line medicines. But extensive research shows that their should not be classified as first line and second line medicines but medicines affecting one or two neurotransmitter systems. Depression is a chronic ,recurring disease with very few patients recovering fully. I mean to say,people get better but not return to premorbid state where all symptoms are reversed. so there is understanding that those affecting two systems is better than those affecting one. Itis not possible to tell how many patients are prescribed this medicine ,it depends on the preference of the doctor . I feel these should be used as single agent as primary drug but others may differ. If there is inadequate response, there is a protocol to be followed like increasing the dose, checking serum level of drug or argumentation strategy.
how long? depends on many factors . There can't be a general rule but duration has to be customized according to the estimation of chances of relapse but more than two episodes or partial recovery , genetic loading leads to a life long treatment . It is good for the brain. Repeated episodes, discontinuing medication, stress or drug abuse can result I loss of efficacy of drug.
It is sad that your child has a relapse of depression. if he has taken 60 mg for 3 months, dose may be raised to 90 mg and look for response. There can be a co morbidity like ADHD, drug abuse or low serum level. It can be augumented with other medicines like Wellbutrin which acts on different system in brain.
Dr Saatiish Jhuntrraa

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Brief Answer:
Please read carefully the answer to each question

Detailed Answer:
Hello,

1. Getting blood level of this drug is as simple as any other lab test. Go to a lab doing this test , give a blood sample and get a report. However blood level does not predict side effects, but if some body is not showing response, we want to know whether the medicine is reaching the site of action in sufficient quantity.

2. Side effects vary from person to person because of genetic makeup, person's determination to take medicine and base line tonic firing of autonomic fibres. Some may not tolerate very low dose and some other not affected by high dose. At this point, I do not have predictive figures since there is no centralised data base on this drug. But based on my experience with this medicine, I haven't had single patient with serious side effects from cymbalta.

3. As there is no centralised date to know how many physicians prescribed which drug and how many patients needed augmentation either due to loss of efficacy or primary partial response. A very large study conducted across 14 countries with large sample size of patients showed that is a patient is given trial of 4 different medicines in full dose for 12 weeks each, only 67% recover fully! others get better to variable degree?

4. Last question is why there is rebound symptoms then a drug is stopped ,suddenly or slowly?
the reason for symptoms is acute shortage of norepinephrine in XXXXXXX synapses because absence of drug results in release of inhibition on HT and Norepinephrine transporter ,there by these are transported back in to neuronal terminal . Stopping the drug has to be customized according to patient's tolerance to withdrawal effects. So sometimes it may take up to a few months to completely stop the medicine.

I hope I have answered all your questions.

Dr Saatiish Jhuntrraa

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