QUESTION:

In what order, and at what doses, does one introduce Prozac, Buspar, and Tegretol? Is Tegretol still necessary when Buspar is taken? Or is it only one or the other?

DR. HELLER'S ANSWER:

First it depends upon how severe the BPD is.

If anxiety is the main problem I generally start first with Buspar 7.5mg twice daily for a week, then 15mg twice daily. One week later starting Prozac and if needed one week later starting Tegretol. I usually consider side effects from Buspar to be diagnostic of the GAD. These side effects are generally the sensations felt when anxiety is very severe. If intolerable very low doses are necessary, gradually moving up. Some patients have to smash the pill and go up very gradually - using a pinch daily for a week, etc. In the early stages Buspar causes far fewer side effects if taken with a complete meal. Taking it on an empty stomach causes rapid absorption leading to tremendous side effects, like "chugging" alcohol Vs sipping it.

Usually the BPD is the more severe problem. Prozac 20mg daily is usually my first option - with food for the same reasons as above. This is done for one week - warning the GAD patient that it may be a rough week. Tegretol is added mid afternoon on the 7th day, and if needed is a total miracle. I will then add Buspar at the same doses.

Tegretol is usually a temporary medication, and only for patients with chronic dysphoria and/or dissociative symptoms. Otherwise I prescribe low dose Haldol for stress induced symptoms, adding Tegretol if Haldol doesn't work because the stress has triggered too much of a reaction in the brain.

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