Q. I am a 35 year old single mother of a 15 year old daughter. My daughter's father, with whom she has had no contact for seven years, suffers from an Antisocial Personality Disorder. My daughter suffers from ADHD, Depression (possibly bi-polar), and Oppositional Defiant Disorder among other difficulties. While a psychiatric inpatient at Mass. Gen. Hospital in November and December of 1999 I was diagnosed with BPD.

Since a child, I have suffered from serious Refractory Atypical Major Depression. Over the past 20 years I have tried almost every anti-depressant known including the MAO Parnate. While living in Pennsylvania I began taking "mega" doses of various drugs under the auspices of the Director of Neuropsychiatry at The University of Pennsylvania. Finally, I obtained some minor relief with seriously high doses of Prozac. My depression, which usually feels like grief, was relieved to the point of dysthymia.

About five years ago I moved to Florida to be near my family. Since that time, I have been unable to find adequate care. (The Prozac "pooped out" about 3 years ago.) Now my family has moved to just outside Boston, Mass. I joined them here in October. When I arrived in Massachusetts, I was taking high doses of Wellbutrin, Effexor, Serzone, and Neurontin. In addition, I was taking Imitrex for my migraine headaches and small doses of Klonopin. After becoming suicidal and deeply angry after a personal disappointment, I was admitted to Mass. Gen. While an inpatient at Mass. Gen. I received 3 ECT sessions. (Which is why I can't remember the exact doses of the meds listed). I suffered terrible headaches and nausea afterward in spite of getting a Tylenol suppository prior and two Percocet afterward, while still in the recovery room. Several hours after the third session (the first where I believe I got any relief) I developed arterial atachycardia of an undetermined source and was transferred out of psychiatry into cardiac care. Two mgs of Ativan IV failed to bring my heart rate down at all. A beta-blocker given IV while I was on the table was used to get it slow enough to get an echo cardiogram which shows no injury to the heart. Nothing was able to slow it sufficiently to get a stress test completed. I am currently scheduled for additional cardiac follow-up as an outpatient.

When I arrived at the psychiatrist I was to see as an outpatient, he literally turned me away due to the difficulty of my case. Therefore, the Director of Inpatient Psychiatry at Mass. General has met with me and has arranged for me to be seen by the attending psychiatrist who saw me there as an inpatient. I am on a waiting list to be accepted in the outpatient clinic. I am on disability and receive Medicaid as my only insurance. My finances are more than just tight.

Pending diagnosis of the source of the atachycardia the doctors are holding off further adjustments on my meds. Additional ECT has not been ruled in or out. Right now I am feeling better than I have in the past 3 years, but it is unclear why. The Director says it is too early to believe it is the meds, perhaps it is the ECT. He also believes they will be able to find an appropriate combination of meds for me. I am currently on 45mgs of Remeron each night. I also take half of a 25mgs tablet of Atenolol each night for the atachycardia. I have tried to stop it as recently as four days ago, and the atachycardia returned 48 hours later. I also take 150mgs EffexorXR each morning to help me get through the day. Right now, this is all I take. My original discharge plan was to include up to 60mgs Remeron, 350mgs Effexor and Depakote. I have nixed the Depakote and everything else is on hold. The Director believes it is best to concentrate on an appropriate combination of anti-depressants prior to trying to add a mood stabilizer. He also told me there is a new anti-depressant coming out in March that I should definitely try.

My daughter, over whom I have almost no control, refuses to move to Massachusetts and wants me to move back to Florida as soon as I can. In spite of our difficulties, we are very close She has no other parental figure in her life. She is living in Florida with her 18 year old boyfriend. I do speak with her every day and she is doing as well as can be expected. Actually, she is doing better than when I was there with her, but very sick. I have contacted the University of Miami in the hope they can help me with my follow-up care, including counseling.

I have several questions. First, do you know of any source of superior psychiatric care in the tri-county (Palm Beach, Dade and Broward Counties) area of southern Florida that might be appropriate for me medically, financially and as a source of therapy? Second, what can you tell me about the new anti-depressant that is due out in March? Third, what advice can you give me regarding relief for side effects associated with ECT? In spite of the absolutely miserable time I had, I would go through it again if it appears that it is the ECT that has brought me the relief I am experiencing.

I have not been in therapy because my most recent psychiatrist in Florida believed it unnecessary. However, for various reasons, I believe the BPD diagnosis is correct. While he did not personally evaluate me for BPD, the Director acknowledges it may make my recovery more difficult. While he agrees with your belief that proper meds are my first priority, he absolutely believes many of the problems associated with BPD are learned behaviors and, as such, can be UN-learned. He strongly advised me to seek (specifically) Cognitive Behavioral therapy.

While you do not need to print this portion of my letter, I assume you know that I am in very capable hands right now. To leave here seems untenable. But I miss my daughter terribly and she needs me. If I force her to move she will run away. I have read many of your answers on this site and you seem to be the most informed source of knowledge I have yet come across on BPD. Of course, my own psychiatrist knows my case best, but any additional information or specific advice you could give me would be welcome. I am especially interested in finding care near my daughter.

A. The last letter was all I got from cyberspace. As far as cardiac problems, I was not aware there were any with Effexor other than fairly minor episodes of increased blood pressure. I use 450 mg/day of the XR in my patients in 4 of 5 cases. Its how much most folks require for a complete response.

The last new antidepressant I heard about was raboxetine, which is coming out through Pharmacia-Upjohn. I am not sure why it is not out already, but hope it works.

I do not know where you live in Florida, and am not sure what to tell you about referrals without a more specific area. If you are around a University teaching hospital, that is usually a very good place to start.