Q. I am a 39 year old male with a diagnosis of BPD, treatment resistant depression and dysthymia. I suffer from severe depression and cyclical thinking that sometimes leads to what I have been told are irrational thoughts and a very distorted view of myself.

I took medication for depression for the first time in 1984 (Nardil) and have been tried on numerous meds and combinations since then. When I was first tried on Prozac (20 mg) it caused a very dramatic improvement in my depression. After about 1 year it stopped working.

I have been on many drugs since then, including combinations of Prozac and other medications. The highest dosage of Prozac I have been on is 40 mg/day. My question is: should I continue trying other medications or give Prozac another try at a higher dosage. I have been on Zoloft, Effexor XR, Celexa, Serzone, Wellbutrin, Lithium, Remeron and other meds with little or no success. I have had some problems tolerating the medications because of weight gain and sexual side effects. Most of the medications that I have tried have not been at the dosage levels you have indicated for success.

A. Virtually all the medications that help in BPD can cause weight gain down the road, and most cause sexual dysfunction. Serzone does neither, but you need to be on at least 500 mg at bedtime (take it all at bedtime, as once daily dosing seems to work well). Also, Serzone does not work very well if you have any obsessive traits. It is a very good medication, but seems to have a less broad spectrum of efficacy than the other serotonergic antidepressant in BPD.

Effexor works at higher dosages, and seems to have less sexual dysfunction than the SRIs. It is interesting that sexual dysfunction actually seems to go down with Effexor as dosage goes up. However, there are no guarantees that sexual dysfunction will not occur.

Prozac is also very good, and may well work at higher dosages for you. We used 80 mg daily in our published studies with good results. You can discuss it with your physician and see what they think. If you need references for any of the published studies, they should be available through this web site.