Q. Doctor, I am huge believer as well as advocate of your medical
approaches. I, myself am a Prozac user and have found great success with it at 60 mg. My question to you is why do you have
such a "80 mg only approach" to using Prozac? I've seen much of the literature you've
written and regardless of the person's question you near always recommend a very high dose of an SSRI only?
As in all medicine is it not true that people metabolize different medications differently?
Also, people each react differently to the same dosage. Whereas one person may need 30 mg of one drug where another person gets the same
effect at a lower dosage. Isn't it desirable to use the most minimal approach in prescribing that achieves the desired effect? In this way
side-effects are reduced and future titration is possible, as well as being cheaper sometimes to the patient at a lower dose.
True as it may be that your studies show 80 mg of Prozac to be superior than less amounts (which is a very "black and white" view) if someone
reacts fully at 20 or 60 mg why push them to unnecessarily use 80 mg of Prozac when it's probably unneeded.
A. A good question. I believe in the higher dosage overall for a couple reasons. First, in the studies in the literature, 60 was not as good as 80. Your point, however, is well taken that some folks should be able to do as well on 60 (maybe even lower). My concern with this approach is that it usually means waiting. The patient must wait to see if the medications are "enough." Likewise, it suggests to the doctor that they need to wait a period of time before increasing. If I was sick, I would not want to wait one minute longer than I needed to be well. I want the idea to be there that BPD is a biological illness, and needs a specific treatment. Thus, there would be fewer treated adequately and it would take longer if we did the gradual titration routine as if BPD were depression.
If you go to 80 mg, and if it were more than needed, you could always try to decrease the dosage after the individual is better. We tried this in the past for two reasons. One, maybe the individual could get by on lower dosages, and two, maybe an individual does not need as much Prozac after they are better. We did not have any cases where this worked.
If all your somatic complaints are gone, no anxiety, no mood swings, normal sleep cycle, etc., stay at 60 mg. It is enough. You are absolutely correct. You would also be different from the vast majority of folks we treated. It also brings up the question, why do you need 60 mg? The OCD studies show 20, 40 or 60 is equally good. None of the BPD studies show particularly robust efficacy at all dosages like OCD.
I have no idea why it works better at 80, but it does. Based on how Prozac is supposed to work neurochemically, I am not sure why anyone needs more than 10 mg daily.
