From the Guidelines
Adding Wellbutrin (bupropion) to Lexapro may be an appropriate treatment strategy for this 43-year-old female patient with anxiety/panic disorder who is experiencing persistent sadness and crying despite Lexapro 15 mg daily, as evidenced by a systematic review and network meta-analysis published in 2023 1. This combination therapy can be effective because Wellbutrin works differently than Lexapro by primarily affecting dopamine and norepinephrine rather than serotonin, potentially addressing symptoms that aren't responding to Lexapro alone. Some key points to consider when adding Wellbutrin to Lexapro include:
- Initiating Wellbutrin at 150 mg once daily for 3-4 days, then increasing to 150 mg twice daily if tolerated, with a maximum recommended dose of 400 mg daily, divided into two doses.
- Monitoring the patient closely for increased anxiety or agitation, as Wellbutrin can sometimes worsen anxiety symptoms in sensitive individuals.
- Addressing the work stress through therapy, stress management techniques, or workplace accommodations as an important complementary approach to medication adjustment.
- Considering alternative augmentation strategies like buspirone or a different antidepressant if anxiety symptoms worsen with Wellbutrin. The evidence from the systematic review and network meta-analysis suggests that various switch and augmentation strategies, including adding bupropion to an existing antidepressant regimen, can be effective for patients who do not respond adequately to initial treatment 1. Additionally, the American College of Physicians recommends that clinicians modify treatment if the patient does not have an adequate response to pharmacotherapy, and that patient status, therapeutic response, and adverse effects of antidepressant therapy be assessed on a regular basis beginning within 1 to 2 weeks of initiation of therapy 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Patient's Current Condition
The patient is a 43-year-old female with a history of anxiety/panic disorder, currently taking Lexapro (escitalopram) 15 mg daily. She reports not feeling well-controlled and experiencing increased sadness and crying, with work stress being a contributing factor.
Treatment Options
Considering the patient's current medication and symptoms, the question arises whether adding Wellbutrin (bupropion) to her regimen is appropriate.
- The provided studies do not directly address the use of Wellbutrin in combination with Lexapro for anxiety/panic disorder with comorbid depression 2, 3.
- However, a pilot controlled trial compared the efficacy and safety of bupropion XL with escitalopram in generalized anxiety disorder, suggesting that bupropion XL may be useful in treating GAD 4.
- A network meta-analysis compared the efficacy and acceptability of first-line drugs for the acute treatment of generalized anxiety disorder in adults, including SSRIs and SNRIs, but did not specifically address the combination of bupropion and escitalopram 5.
- Another study discussed the therapeutic value of crying and the importance of emotional support, which may be relevant to the patient's increased sadness and crying 6.
Key Considerations
- The patient's symptoms of sadness and crying may be related to her anxiety/panic disorder, work stress, or a combination of factors.
- The use of bupropion in combination with escitalopram may be considered, but its efficacy and safety in this specific context are not well-established in the provided studies.
- Further evaluation and consideration of the patient's individual needs and circumstances are necessary to determine the most appropriate treatment approach.