Q. My 20 year old son was diagnosed at 7 with a reactive depression, at 10 with ADHD superimposed on major depression, at 14 the diagnosis became Bipolar I including "features of BPD". He takes 1200 mg lithium and recently began 2.5 mg of Zyprexa at bedtime (to help him fall to sleep). Since his diagnosis its been noted by myself and others that Lithium is not sufficiently controlling his symptoms. The diagnosis of "BPD Features" has never been pursued. Recently, I came across information about BPD. It seems to me that many of his residual symptoms sound BPD in nature: dysphoria, chronic irritability, cutting himself, angry outbursts, reckless driving, problems with the law, problems sleeping at night, etc. He says he frequently feels depressed. He doesn't appear depressed though, just angry and irritable. Prior to being well stabilized on lithium he was given Zoloft and Wellbutrin which rapidly resulted in anger, irritability, psychotic symptoms and were discontinued. What other medication(s) might work with the lithium and Zyprexa to manage the "BPD Features" given that he reacted badly to the antidepressants?

A. It is hard to say why he responded poorly to Wellbutrin and Zoloft. Wellbutrin can increase anxiety and anger in Borderlines when it is given alone. Zoloft can cause anxiety initially in some. A good try of antidepressant may be Serzone as 500 mg at bedtime. If he has OCD it does not work very well, but if not, it is pretty good. Start at 100 mg at bedtime and increase by 100 mg every 4 or 5 days.