Q. My question that I have is in regard to mood stabilizers. I will give you a bit of history in hopes that it will help you to give a more accurate response. For the last five years I have been diagnosed with depression. Then in January of 1999 I was also diagnosed with BPD.After hearing about BPD I read a lot about it and feel that I have an accurate diagnosis. I have a history of many medications. At first I was treated with antidepressants alone. First Prozac in a dose of 20mg
for six weeks, which I felt did not help at all. Then the dose wasraised to 40mg for six weeks. Again, I felt no change. The Prozac was raised once more to 60mg but then when I started to feel a change Ididn't like it because I became very jittery and agitated. The psychiatrist changes meds at this point to Effexor XR. first 37.5mg and then up to 75mg. I felt absolutely no change. Then manerix. I was eventually on a max dose of manerix. Manerix alone made me weird. I don't know for sure if I have ever been manic yet on manerix alone I think I may have been. I was always very hyper, and words would fill my brain faster than I could speak them. I was very rude sometimes to the point of embarrassing others who were with me. I would say whatever thought came to me without thinking. Worse yet was that I didn't realize how rude I was being until it would be pointed out to me later in private. When it was pointed out to me what a change I had experienced I went to the psychiatrist with this information. Another medication change. Back to Effexor (which still did nothing for me) and then a try with Zoloft. Zoloft made me too nauseous to continue with it for more than a couple weeks. Another change. I had paid close attention to what each med did to me and I suggested another try with manerix but this time along with a mood stabilizer. My psychiatrist
agreed to give it a try. Manerix 300mg bid along with Lithium 300mg bid. With this dose of Lithium my therapeutic blood level was a steady 0.7. Low, but within a therapeutic range. Lithium gave me tremors for about 6 weeks but I tolerated it because I felt more on an even keel than ever before. My friends noticed the good change and would tell me how much better I seemed to be. I stayed on this combination for a long time for probably about 10 months to a year. Then I decided I didn't need meds. I thought I could keep myself ok without them. I suppose I didn't realize how much it was doing for me. I ended up in the hospital eventually. (7 times from Jan. 1999 to Aug. 1999) During these hospital stays was when I had meds changed a few more times. Because I didn't like the shaking side effect from the Lithium my psychiatrist went with Epival and Manerix. I don't think the Epival did much for me. On the next round of hospital stays I had a different psychiatrist because I moved to a different city. I was still taking the Manerix and Epival when I moved but I started to gain so much weight that I refused to continue taking it. The new psychiatrist started Neurontin with the Manerix. I don't recall the dose of the Neurontin but that would be irrelevant because I didn't stay on it long. I thought that Neurontin was making it impossible for me to lose the weight so I stopped taking that too. I decided that I would tolerate the six weeks of shaking from the Lithium because it was the only stabilizer which wasn't causing me weight gain. Back on the only two meds which had ever helped me. But the meds were not giving me the same effect as they had the first time. I was still cycling in and out of "moods" badly. I was suicidal and
cutting, etc. I decided that meds did nothing for me and I stopped taking all medication before Christmas of 1999. Since that time I took no medication and quit seeing my psychiatrist. I hated the psychiatrist I was seeing in this other city. Then in March 2000 I moved back to the city I was in before and managed to get in to see my old psychiatrist. I respect this psychiatrist and so I decided I would give medication one more try with her. Before my appointment with her I had written a letter to you which you responded to. You had mentioned Serzone at a dose of about 500mg might be a good idea. I told her this and she agreed to give it a try. I have just started on Serzone now. As I write this letter I have taken it for 2 days. For the first 4 days I am to take 50mg bid. Then for 1 week I am to take 100mg bid. Then for a month I am to take 150mg bid. At that point we will evaluated the results. She said that if I am not noticing a difference after 150mg bid for a month we will go to 300mg bid before deciding it doesn't work. She was encouraging me to also take a mood stabilizer. I said that at this point I didn't want to because of the weight gain and
because I didn't like the shaking that Lithium causes for me. She is concerned that an antidepressant alone may make my mood go too high. My question to you is..... With my history of rapidly changing moods do you feel that I will need a mood stabilizer? When I say rapidly changing I mean that I can be extremely happy for a few hours or so...maybe even a couple days, then I could go completely to the other side of the scale to suicidally depressed. When a bad depression hits it will often last for a very long time (months) but often my mood will jump all over the place. I have extreme states of dysphoria sometimes. I go into rages that I somehow manage to keep bottled up. I will get extremely angry yet not yell at other people or get into any physical fights but instead what happens is that I literally vibrate with anger and I used to release this by self injury. I have not self injured in about 8 months now. I have some tranquillizers which I now take when I get extremely angry. (I take either 1mg of Ativan or 0.5mg of Xanax) I realize that benzodiazepines are not good for borderlines but I justify that the odd tranquillizer is better than self injury. I have not abused tranquillizers in over a year now. I used to abuse tranquillizers and was not prescribed any for quite some time due to that. (A few times I felt that 10mg of Ativan would be ten times as good as 1mg) After a couple of these episodes I was no longer allowed to have them. I was prescribed more when I moved to the other city and since Aug 1999 I have only used about 10-15 of them and have not abused them in any way. One last question in addition to asking if I would need a mood stabilizer.....Do you think that one can experience mania from antidepressants alone if one is not bipolar? I apologize for the lengthiness of this letter but felt it important to give a fairly thorough history. I would appreciate any input you have on these two questions.

A. If you were my patient, I would not use an antidepressant with the Serzone. Serzone is a 5-HT2 antagonist, and has no reuptake properties of serotonin or  noradreanaline at all. 5-HT2 antagonists work well as antidepressants if you are not obsessive compulsive. They are also calming, and have no weight gain when properly prescribed. To an extent, they are like partial atypical antipsychotics, which are also 5-HT2 antagonists.

As a side light, if you are sedated by the Serzone, it can all be taken at bedtime. Do not do this without discussing it with your psychiatrist first. The nefazodone (Serzone) is broken down into a compound called a triazole idonea, which is probably what makes Serzone work. Because of the 
biochemistry for the triazole dione, once daily dosing, combining the morning and evening dose at bedtime, is probably okay.