Can Prozac Be Taken With Bipolar?

QUESTION:

Dear Dr. Heller,

My son is bipolar.  He is 13, 170 lbs., 5'11 ½".  We just got a new doctor.  He has been on Tegretol XR (1200 mg 400 3x a day), Risperdal (1mg 1x a day), Wellbutrin (150 mg 2x a day), and Tranxene (3.75 mg 3x a day).  He has done well on these medicines for about a year, he started these medicines November of 2000, after his father died of a heart attack.  Initially he was on Depakote for about 3 months but discontinued because he gained 60 lbs.  His father was also diagnosed bipolar, as are his 2 sisters.

He started complaining of abdominal pains and migraines since November 2001.  He's had ultrasound of the liver, spleen, a GI series, which were all normal.  His alkaline Phosphatase is 370 (3x normal) both doctors have told me this is because he is growing, since all the other liver enzymes are fine.  However the new doctor is weaning him off the Tegretol and replacing it with Neurontin with is not helping.  He needs the Tegretol, but is it true that the enzyme is up because he is growing, is it safe for him to take it?  He goes to private school but is going to be home schooled until this is worked out.  His schoolwork is suffering because he cannot go to school due to the migraines and abdominal pains.  He says it hurts too much.

He cannot structure his time or organize his work and he feels the dysphoria you talk about in BPD.  I read some of you fags to him and he feels this is what he has also.  Would Prozac be dangerous for him because of the bipolar? Also, if he cannot take the Tegretol what do you recommend?  Thank you for any help you can give my son.  I am very glad that my son taught me how to use the Internet (else I don't know where my 3 kids would be) or I would have never found your site - which I stumbled upon by accident - but I believe it could be a life saver.

ANSWER:

I have been extremely disappointed with Neurontin for the BPD.  Tegretol is significantly more effective for the BPD than any other mood stabilizer, although in some patients Depakote works well.  I treat all my bipolar with BPD patients with Prozac.  It can trigger mania so I generally prescribe an antipsychotic for a while.  Incidentally Wellbutrin can also trigger mania.

He probably has ADHD also, and may also have the generalized anxiety disorder.  My screening test may be of help in this regard.  I cautiously and carefully give my bipolar with ADHD patients stimulants, but observe them very carefully.