Q. My 24 year old son has been diagnosed with BPD. He is also delusionally paranoid, has somatic health concerns, and has had psychotic episodes. There have been problems since he was a child and, after his first hospitalization at age 15, was (mis)diagnosed with OCD and given Anafranil & Mellaril. These had no perceivable effect aside from weight gain and lethargy. He stopped taking the meds at 18. Between the ages of 18-23, he lived independently and was very high-functioning.

In April 1999, as a result of an extremely stressful situation, he decompensated and has gradually gotten worse to the point of not leaving the house. He is convinced that his 'enemies' have done something to give him heart problems and that he is dying. He was seeing an clinical psychologist and a psychiatrist who prescribed Zyprexa that my son won't take since one of the side effects relates to the heart (his favorite book is the PDR). He, of course, denies he has any psychological problems.

I was very interested to see that you recommend Effexor, since I have had very good results taking it for depression (150XR). Given the above history, do you feel he might benefit from it? Do you have any advice at all on how to convince someone to take meds?

A. Your son's situation is unfortunate. I cannot tell if he has a psychotic depression poorly treated, schizophrenia, schizoaffective disorder, schizotypal personality, or borderline personality.

The OCD may have been there, but if your son had concomitant borderline personality, Anafranil would be a bad choice, and not very helpful most of the time. That was in the past, and if it was over 10 years ago, probably a good treatment choice at the time.

His treatment will be based on the diagnosis present. Every diagnosis listed above can be treated, but some have better outcomes than others. I cannot tell you what may or may not work on the data provided. If he still is psychotic/paranoid, Serzone may be a good choice, since it has similar binding properties to the antipsychotics without the side effects. However, if he has OCD, Serzone is not effective. If he is more borderline and or schizotypal than anything, Effexor or Zoloft or Prozac could all be good choices. If he is paranoid and delusional all the time, he probably would benefit most from an antipsychotic.

Getting someone to take the medications seems to be dependent on their insight. If he feels there is nothing wrong mentally, chance for decent compliance will not be very good. Stick with him, but do not expect miracles without any insight.