Q. Dr. Markovitz,

What medication(s), besides cognitive therapies or support groups would you suggest for treatment of someone that has BPD traits, major depression, and a tendency towards addiction with alcohol and marijuana? This person is already on Seroquel, Neurontin, Paxil, and Remeron. The side effects have been major weight gain and very high cholesterol. What do you know about Naltrexone?

A. I have a preference for Effexor XR, Serzone, and Zoloft in borderline personality disorder. I use them statistically in that order, too. If you have enough medication in the person, carbohydrate craving should go away, as well as all somatic complaints (headaches, migraines, PMS, irritable bowel, TMJ, neurodermatitis, fibromyalgia, and nocturnal myoclonus). This is usually 450-600 of Effexor XR, 500-750 of Serzone, and 200-400 of Zoloft. The uses of Zoloft and Prozac are discussed in Impulsively and Aggression edited by Hollander and Stein. I wrote the treatment chapter.

Since then, we have published on Effexor (Psychopharmacology Bulletin, 31:773-777, 1995. The Serzone data will be part of a chapter I wrote for a book edited by John Livsley that will be out in April or May of 2000.

Naltrexone is so-so. Eric Konicke did a paper on this a few years back (I think it was in Psychopharmacology Bulletin around 1991 or 92). It stops working after a short time, and only seems to help with self-injury. I have found all the antiepileptic agents to be depressogenic, and avoid them if possible. All the atypicals probably mediate their beneficial effects through 5-HT2 antagonism, so Remeron is a good choice, but Serzone is better so you do not get your patients as fat. Use the Serzone as an hs dosage. Start at 100 hs, and increase to 500 hs as tolerated.