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- 02 January 2020

How medicines should be used

The choice of proper pharmacological therapy constitutes a complex process aimed at not only the disappearance of symptoms, but also the improvement and prolongation of the individual's life.

To achieve these goals, a course of sequential adaptation of therapy based on the unique and specific characteristics of the person being treated is necessary. The secret to effective pharmacological therapy is personalization of treatment.

Symptoms are not enough

There is no one-to-one correspondence between the symptom and the cause. Thus, there is no one-to-one correspondence between any symptom and specific medication.

With the recent development of clinical psychiatry, physicians may distinguish between medications that treat symptoms and medications that modify and reduce vulnerability to disease.

So, the doctor must choose the medicine that acts on that brain circuit affected: the symptoms serve to orient a medical context, but they must be translated and interpreted: today this type of approach to the clinic is called “translational.”

It has been scientifically documented that “It takes hospitals and clinics about 17 years to adopt a practice or treatment after the first systematic evidence shows it helps patients" (Harvard Business Review).

The delay in evidence-to-practice causes some patients to take off-label medicines: it means that their symptoms or diagnosis are not among those already approved and indicated in the information sheet of the chosen medicine.

Physicians often combine medications for the treatment of depression, but this should not be done by simply matching the sum of symptoms to the sum of medications. Particularly in the elderly, the interactions and side effects become incalculable, and it becomes necessary to reduce medications rather than to increase them.

We must all remember that the goal of treatment means to improve and lengthen life, and not merely to aim at the symptoms reduction. The two goals do not always coincide.

Minimum Therapeutic Dose

After the choice of the right medicines, it is important to individualize the achievement of the minimum therapeutic dose, which will be defined specifically for each person. The guidelines, on this aspect, do not report valid data for every subject.

We know that there exist countless variables that determine the metabolic change from the absorption of a particular medicine: without the ability to administer a consistent dosage of any medicine’s absorption levels into the blood, we can only attend to what the patient tells us, as the guide to identify the right treatment.

Each person responds in a specific way to each medication

If the medicine does not reach the minimum therapeutic dose, it fails to work; and, it could make the person intolerant to that medicine, which implies the person will no longer be able to take it, even if it turned out to be the right one with a different dosage.

Modern medicine and psychiatry propose a personalized approach beyond strict guidelines and standardized treatments.

Therefore, in addition to providing any useful information on the effects of new medicines, whenever possible, Dr. Pallanti prefers that the patient not be left alone to experience the effects of a treatment, but that any effects take place in the controlled environment (Day Center).

Dr. Pallanti tries, with a method validated by his experience, to arrive at the personalization of the treatment that achieves the minimum sufficient to correct the disorder and no more.

The dosage proves fundamental because in some cases a different dose of the same medicine corresponds to different functioning: today, in fact, these medicines are defined as “multifunctional.”

In these cases, we could say that we are dealing with different medicines in the same molecule, when employed using different dosages.Such differentiations define an art, measured.

Frequently, patients with psychiatric disorders have multiple comorbidities: for example, those with compulsive behaviors such as Trichotillomania may also have anxiety, depression, sleep disturbance, and more. These disorders often persist for a long time.

We cannot treat everything in one solution, so we should proceed in stages: a procedure should establish priorities and a hierarchy of goals.

Normally, the first target is the one related to the most disabling disorder: having improved that one, we go on treating other aspects.

Sequential adaptation of therapies

Each therapy, whether involving pharmacology or neuromodulation, may have a sequential adaptation or have different objectives; it may be designed for different diagnoses.

To give an example: the patient arrives in a severe state of anxiety - which becomes the primary objective at the beginning of the treatment - then a background of mood depression emerges that has facilitated the anxiety. We modify the treatment; and finally, when we have eliminated the anxiety and depressive symptoms, perhaps problems with attention and concentration may emerge. Again, the treatment will have to change target.

Duration of Treatment

Once the condition has improved, why do we have to continue taking the medications or perform the follow-up, neuromodulation treatments?

Why must we do the checkup visits very frequently if the treatment works?

Because we know that behind every disorder there lurks a vulnerability in the system that only by maintaining adequate protection over time, can be controlled, and even canceled.

The appearance of therapeutic effects varies from person to person: in some cases, we might observe an improvement after a few days, but sometimes, it can take months. Effective therapies modify the functioning of brain circuits, thus improving the condition; but even after the appearance of therapeutic effects, it remains necessary to maintain what has been restored.

The brain exists as a “plastic,” adaptive organ, and the medicine and the neuromodulation will allow it to adapt in the best possible way, to use its plasticity well: but for these salutary modifications to happen without the symptoms’ recurring, it will be necessary to continue and to balance the dosage according to the circumstances and the environment.

When we follow our own protocols, it will be possible to avoid or at least minimize the risk and severity of relapses because in that case it would take much more time and effort to correct the dysfunction.

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