Q. My almost 21yr old daughter has been struggling for 7 yrs, 4of these acutely, with symptoms of anorexia requiring hospitalization several times, progressing to bulimia alternating with anorexia and has been treated as an eating disorder patient, even though' these symptoms are only a very small part of her problems. she has manic periods followed deep long lasting depressions when she tends to abuse alcohol, she has self injured herself constantly for years by cutting, interfering with wounds, burning. she rages inside but is incredibly controlled on the outside. she dissociates, has loud abusive voices in her head has had a recent, almost successful attempt at suicide and many other problems of this ilk most of which she wont talk to me about. I feel that the psychiatrist is treating her with restricted vision and I also feel that in South Africa there is little understanding of mental disorders of this nature. Her medications at the moment are: Effexor XR 225mg daily, Tegretol 200mg bid, Mellaril 50mg noc and Dormicum 15mg noc. I did not mention that she has severe insomnia and has had for years. the dormicum has limited efficacy 4 hrs per night. do you have any advice for her and her narrow minded psychiatrist?
A. I feel sorry for your daughter, but truthfully feel her psychiatrist is doing a pretty good job. Treating the eating disorder symptoms is probably not all the doctor is doing, but it is the right symptom cluster to follow to know if your intervention is or is not working. I think the interventions to date are very reasonable, and may just need a few minor changes.
Effexor XR at 225 is the top recommended dosage, so the doctor is not being too gentle with the prescribing. However, it may be of benefit to show him our article on similar patients where we use 300-450 mg or so of Effexor XR. It is what most folks like your daughter need with similar symptoms. Tegretol will help some with mania, but will also decrease the serum levels of venlafaxine (Effexor XR) as a side effect. So, if the Tegretol is continued, dosages of 450 to 600 of Effexor may be needed. If the Effexor works, the Tegretol can be discontinued.
The other medications are mostly for sedation. Since she sleeps poorly, they help give her some sleep. If the Effexor works, the sleepers can be discontinued in 6-8 weeks. Do not make any changes in your daughter's medications without consulting your doctor first. He really sounds pretty good.
