Q. First let me thank you for your presence on this web site for BPD. What a blessing it is to have access to a BPD expert who is both an M.D. and Ph.D. You seem to understand the full scope of the problem as well as offer excellent advice for solutions to BPD.

I have been on Effexor SR 150 mg. for 2 years, which was initially prescribed for depression and PTSD. I was diagnosed with BPD about a year ago by an extremely astute psychologist after years of on-again-off-again therapy. After reading your answers to problems related to meds and BPD, I am convinced I need more Effexor (450 to 600 mg according to you, I think). But I wish the problem were that simple. Unfortunately, I have made the matter of my meds a bit more complicated recently, which is why I need to ask for some advice.

I wanted to try to quit smoking in early December so I started taking Wellbutrin (same as Zyban according to my doctor, but covered under insurance), gradually increasing to 300 mg. I did this while still taking my Effexor SR. While I was unsuccessful (still have hope) in quitting smoking, I liked the general feeling I had while taking both drugs. I had a lot more energy and seemed happier, less irritable with fewer mood swings. Life was good! The only problems were that I was terribly constipated and seemed to have increased incidence of anxiety. Consequently, in early January I went off my Effexor (without talking to my doctor, of course) because I thought I could just manage with the Wellbutrin and keep the hope of quitting smoking alive.

While I love the Wellbutrin for its effect of increased sex drive, energy, and control of weight gain, I think I might have made a mistake by going off the Effexor. I have been rapid cycling ever since and initially experienced increase in carbohydrate craving. It's now been 3 weeks since I went off, and am back in the borderline zone. I realize I must return to the Effexor, but my question is this: Should I take both drugs, or just a higher dose of the Effexor SR (450 - 600 mg) to begin with? Can I safely take high doses of both meds? How should I proceed getting back onto the correct dosage of Effexor SR if I must give up the Wellbutrin? I'm worried about transitioning to the correct drug and dosage as I hate all the side effects. I would like to stay on the Wellbutrin but perhaps I do not need to if I am on a higher dose of Effexor. I think my psychiatrist is not as well informed about BPD as you are, so please help!

 

A. This is one of those situations I feared would happen on this website. I will give you some general answers, but am not your doctor, and would do you a great disservice by managing your well-being with so little information and never meeting you for an evaluation.

Wellbutrin as a single agent will not treat BPD. Period. You found this out.

There is no perfect agent, but Effexor seems to cover the greatest number of patients with BPD successfully. Our printed study (Psychopharmacology Bulletin 1996) indicated a dosage of about 325 mg/day works. Some need more, some less.

There is not any reason why you cannot use Effexor XR and Wellbutrin SR together. However, many patients do well when they are on enough Effexor alone. Your chances of stopping smoking if you are still anxious or depressed are very minuscule. If the Effexor XR works, anxiety and depression leave, it will be easier to quit whether you are on Wellbutrin or not. Interestingly, sexual dysfunction seems to go down with Effexor XR as dosages are increased, which is not true with SRIs.

As far as restarting your medications, call your doctor. They have you on the right ones, so follow-up with him or her for your own well-being.