QUESTION:

My daughter , age 15, was diagnosed with severe depression a year ago. She was given 20mg. of Prozac, which was later raised to 30mg. Initially for 2 months she felt better, then got worse and the Prozac was raised to 30mg. This didn't help and she went to 40mg. but too late to keep her out of the hospital. Then Effexor XR was tried and had roughly the same results - felt better for a while, then got worse. - ended up in the hospital for a suicide attempt (overdose).

During her 3rd stay in the hospital, she was diagnosed with the BPD ( after hitting her mother and biting the Psychiatrist and Social Worker). She has all 9 of the criteria and I also believe she has the GAD. We just found out she had been sexually abused by neighborhood boys over a 7 year period. Two weeks ago she started on 20mg. Prozac, and last week raised to 40mg. and also added Buspar at 15mg. then 30mg. While we are waiting for this to work, she is being held together by Risperdal.( very bad dysphoria). My question is: I am beginning to feel that she may need more than 40mg. of Prozac in order to see some positive improvement, but think the psychiatrist is afraid to go much higher because she is a teenager. I had to battle with her to get her to raise the Effexor to 225mg. What is your experience with teens who have BPD, depression, and the GAD.

DR. HELLER'S ANSWER:

Your daughter is three hours away from seeing the dysphoria stop. The addition of Tegretol would make all the difference in the world. The literature shows it, so it's not like trying something that's unheard of. Dr. Cowdry at NIMH showed this in 1987! I've been doing this for nearly 10 years now, and it virtually never fails.

My experience in the short run is that if Buspar is necessary, the higher Prozac doses will make individuals WORSE not better. This is likely because of an imbalance of serotonin, some too high, some too low. Prozac raises them all. Buspar lowers the high ones. Once her mind is slower from the Buspar and the dysphoria is stopped by Tegretol I can then make a decision about whether a higher Prozac dose is necessary, and there clearly are those occasions. There are clear cut symptoms I look for. I have an instruction sheet that I give my patients, and I have been giving it out for free to experts on the BPD. It will be available shortly on this website, look for it under medications.

QUESTION 2:

I have read every single word on these web sites. Without this information, I would be feeling hopeless. My only remaining question is: What do I do about the Risperdal? She's taking 2.5mg in 3 divided doses. Should this be eliminated, or used in conjunction with Tegretol? At this point it seems that the Risperdal is the only thing holding her together. Will Tegretol have the same results or are they administered together and then wean her off the Risperdal? I know how busy you all must be, but this may be the missing piece to the puzzle. And I feel like we are close to getting these meds right.

DR. HELLER'S ANSWER:

It's obviously difficult to make specific recommendations, and I'm not her physician, so I can only tell you what I do with my patients in this situation.

In adults I prefer using Risperdal for crises only. Children and teens sometimes need to stay on it for a while, but again the sooner off the better. Generally once a high normal therapeutic blood level of Tegretol is achieved, I'm able to use Risperdal on a "as needed" basis, or sometimes at bedtime only. The goal is control and feeling good first, then cut back. There aren't hard and fast rules, but I usually add a medication like Tegretol first, then cut back on Risperdal once the patient is doing better.

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