instruction: hi doctor this is about my brother earlier he used to get very angry over small matters he was not able to concentrate on anything and was not able to sleep he was confused and used to think that everybody was watching him he used to harm the family members sometimes he started his medications three months back he was on fluoxetine 40 aripiprazole 10 quetiapine 50 and divalproex 750 he is now calm but has tremors in his hands and legs and feeling numbness in head and is very confused he is feeling as if he is mad he is mostly confined in home and hardly goes out need your advice on what to do and when he will feel better is antidepressant fluoxetine not working
output: hello I read your query and understand your concerns first of all I would like to inform you that three months are generally enough for the antidepressants to show effects secondly 60 my of fluoxetine is generally a sufficient dose for antidepressant purposes considering the fact that there is some response despite the presence of adequate dose for sufficient time indicates the possibility of partial response thirdly the above observation is not unique as problems are often encountered in patients with long duration of untreated illness now regarding the tremors I think divalproex is likely to cause tremors as a common side effect in my opinion 250 my of divalproex has a little role on this day as his aggressive behavior already reduced regarding the next course of action I feel adding another antidepressant is the first option in case there are reasons for not doing the same adding low dose antipsychotics can be used provided there is aggressive behavior still present I often prefer low doses of olanzapine my to boost up the effect of fluoxetine I must assure you that over a period of time he will improve further I hope this helps