Q. My 22 year old daughter is a severe self injurer We have tried SAFE alternatives in Chicago, NY Hospital DBT program in White Plains, NY. Private psychotherapy. She's been hospitalized for the past 3 1/2 weeks due to an overdose. She has many scars including 3rd degree burns, skin graft after a cigarette lighter self inflicted burn etc. What else can we try? The hospital suggested DBT.

A. A couple things to consider. If she has not been on medications, she has not yet been treated with anything that has much of a chance of working. Second, even if she has, dosages of medication are extremely important. We have shown that how much medication you take is irrelevant. It is a matter of how much medication gets to the site of action. This is really the whole basis of pharmacology in general. That is why some folks need 1 aspirin for a headache, others 2, and some 4. It is not how much you swallow, it is what the level is in your blood stream.

My reasonable guess is that she smokes either cigarettes, or marijuana, or both. Each will cause serum levels of antidepressants to go down. The bottom line is she needs to take more to work. Thus, she may need 450-600 mg of Effexor XR, or 400 mg of Zoloft, or 750 mg of Serzone. Likewise, our data suggests about 15% of the population have low levels of medications even if they are not smokers. Thus, there are a lot of reasons why some folks need more medication than others.

There are no guarantees these medications will work, but most of the time one of the three works very well. As with all fields of medicine, therapy comes after you fix what is physically wrong, not before.