Should I start bupropion (Wellbutrin) in an 82‑year‑old male with Parkinson disease on antiparkinsonian and antihypertensive therapy who has suicidal ideation without plan and nighttime hallucinations, while he is already taking low‑dose quetiapine at bedtime?

Do Not Start Bupropion in This Patient

I strongly recommend against initiating bupropion (Wellbutrin) in this 82-year-old man with Parkinson's disease who is experiencing hallucinations and suicidal ideation. The risks substantially outweigh any potential benefits in this specific clinical scenario.

Primary Concerns with Bupropion in Parkinson's Disease

Psychosis Risk

The FDA label explicitly warns that bupropion can cause psychosis, hallucinations, paranoia, and delusions 1. Your patient already has nighttime perceptual disturbances (hallucinations of imprisonment), which represent Parkinson's disease psychosis (PDP). Adding bupropion would likely worsen these psychotic symptoms, not improve them.

Motor Deterioration Risk

While bupropion has dopaminergic properties that theoretically could help PD, the evidence shows:

• Case reports document falling backward and parkinsonian syndrome in elderly patients taking bupropion 2
• The effect on motor symptoms remains controversial and inconsistent 3
• At age 82, fall risk is already elevated, and bupropion could exacerbate this

Limited Evidence for Depression in PD

The available literature on bupropion for depression in PD is extremely weak 3, 4:

• No controlled double-blind studies exist
• Only scattered case reports show benefit
• A 2022 scoping review concluded there is insufficient evidence to support its use 3

Appropriate Management Strategy

For Psychosis

The 2019 AGS Beers Criteria recognizes only quetiapine, clozapine, and pimavanserin as acceptable antipsychotics in PD 5. Your patient is already on low-dose quetiapine, which is appropriate. Recent expert consensus (2025) recommends:

• Pimavanserin as first-line for PDP based on established safety and efficacy 6
• Quetiapine is "possibly useful" but limited by somnolence, hypotension, and cognitive impairment risk 6
• Consider switching from quetiapine to pimavanserin if hallucinations persist 6

For Suicidal Ideation

The 2025 VA/DoD guidelines for suicide risk management suggest 7:

• Cognitive behavioral therapy focused on suicide prevention (weak recommendation for reducing attempts in those with recent suicidal behavior)
• Safety planning and close monitoring
• Ketamine infusion as adjunctive treatment for short-term reduction in suicidal ideation with major depression (weak recommendation)
• Clozapine specifically for patients with schizophrenia/schizoaffective disorder and suicidal ideation

For depression in older adults with PD, the 2025 German guideline emphasizes that levodopa optimization should be the foundation, as undertreated motor symptoms often worsen depression 8.

Critical Pitfalls to Avoid

1. Do not add bupropion to existing quetiapine - this combination increases fall risk in older adults and bupropion may precipitate or worsen psychosis 9

2. Do not use typical antipsychotics or most atypicals - they will worsen motor symptoms 5, 8

3. Monitor closely for worsening suicidal ideation - the FDA label warns that antidepressants can increase suicidal thinking, especially early in treatment 1

Recommended Action Plan

1. Optimize current quetiapine dose or consider switching to pimavanserin for better psychosis control without sedation/hypotension
2. Ensure antiparkinsonian medications are optimized - undertreated PD worsens depression
3. Implement CBT-based suicide prevention therapy and safety planning 7
4. Consider rivastigmine if cognitive impairment/dementia is present (approved for PD dementia) 8
5. Avoid bupropion entirely given the high risk of worsening psychosis and falls in this elderly PD patient

The combination of advanced age (82), Parkinson's disease, existing psychosis, and suicidal ideation makes bupropion particularly hazardous in this case.