Pyramid Girl - These doses of SSRIs are very individualized and physicians often overshoot the maximally effective dose, but studies show that docs underdose much more often.

Paxil™ (paroxetine), aside from blocking the serotonin reuptake pump in the synaptic gap, also has a high affinity for (strong attraction to) muscarinic receptors. This results in a calming effect.

Paxil has a dose-response curve that eventually plateaus. In other words, at a certain dose (which is different for everyone) the blockade of the reuptake pump is saturated, and adding more Paxil does nothing more therapeutically. The problem with this is that some side effects may get more intense without getting any more antidepressant effect.

Another factor to take into account is how long has your daughter been taking the Paxil? Some start-up side effects (eg. drowsiness, lethargy, headache/pressure, etc.) make one feel worse before feeling better. These usually disappear within a month of taking the Paxil at the target (final) dose.

Start-up side effects occur mostly because before one starts the drug, the body has tried to compensate for the lack of serotonin (more likely 'norepinephrine modulation'). Many of the symptoms of depression arise from this attempt by the body to maintain homeostasis (a properly functioning body) with at least one of the components involved in the homeostatic mechanism malfunctioning.

The addition of serotonin into the body hyper-stimulates any remaining serotonin receptors and plays havoc with neuronal systems controlled by other neurotransmitters. It takes 4 to 8 weeks to expect the best relief from depressive symptoms. This is the time it takes for the concentrations of the various neurotransmitters and their associated receptors to normalize.

I would say that if your daughter is still noticeable lethagic after taking the Paxil for 6 weeks, then the dose should probably be lowered. You would have to monitor your daughter's mood with any dose lowering. Remember, antidepressant effect is mostly independent of the receptor system causing the lethargy and drowsiness. If you lower the dose, the depressive symptoms may return and the lethargy will be that much worse.

This is the art to medicine. A good doctor can fine tune a dose that maximizes efficacy (eg. antidepressant effect) and minimizes adverse effects (eg. lethagy, headache, etc.).

I should mention that Paxil has a substanitated reputation for causing an incidious, delayed, and frustrating weight gain. At first, when taking Paxil, you begin to lose weight (approx. 5-10 lbs) then about 3 to 4 months of taking the drug, you realize that your clothes don't fit.

This weight gain is due to carbohydrate craving; one has to be incredibly disciplined not to succumb. Accessiblity to the Doritos™ and chocolate bars has to be extremely limited, and develop a love of rabbit food (carrots, celery, salads - light or no dressing). It is far easier to keep the weight off through a strict dietary regimen, than to take off the weight once it has been gained. One psychiatric lecturing at a conference that I attended last year said that it appeared, in most cases, that any weight gain in the first 9 months of therapy may be permanent. It does take 6 to 8 months for the cravings to become completely manageable.

Hang in there and discuss your concerns with your daughter's mood and motivation. Depending upon several variables the doc can keep the dose the same, lower it, or even raise it (lethargy is a symptom of depression).

Good luck and lets us know what the doc says - Cam

<font color=orange>"Sometimes you may be shown the light in the strangest of places, if you look at it right"
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