A 12‑week pregnant patient with ADHD, depression, and anxiety taking 150 mg of Wellbutrin (bupropion) reports no benefit; should she stop the medication?

Do Not Stop Wellbutrin—Instead, Optimize the Dose

She should not stop taking bupropion; rather, she should increase the dose to 300 mg daily, as 150 mg is below the therapeutic target for depression and anxiety. 1

Rationale for Dose Optimization

The current 150 mg dose is a starting dose, not a maintenance dose. According to the 2024 AJOG guidelines on ADHD in pregnancy, the maintenance dose for bupropion is 150-300 mg daily, with a maximum of 450 mg per day 1. The FDA label confirms that after 4 days at 150 mg, the dose should be increased to the target of 300 mg once daily 2. She hasn't reached therapeutic dosing yet—this is why she's not experiencing benefit.

Why Continue Bupropion in Pregnancy?

Safety Profile

• Bupropion does not appear to increase major congenital malformations above baseline risk 1
• While small absolute increases in cardiovascular malformations (left ventricular outflow tract obstruction, ventricular septal defects) have been reported, confounding by indication cannot be ruled out and other studies have not replicated these findings 1
• The possible increased risk of diaphragmatic hernia is extremely small given the rarity of this condition (population prevalence 0.012%-0.031%) 1

Risks of Untreated Depression/Anxiety in Pregnancy

Recent evidence demonstrates that untreated depression during pregnancy carries significant risks 3:

• Higher rates of gestational diabetes
• Worsening pregnancy depression
• Increased postpartum depression
• Decreased breast milk production

The consensus from the 2024 AJOG guidelines is clear: treatment with medications should not be stopped if they are required for daily functioning of the pregnant person 1. The magnitude of documented medication risks is very low, and there is evidence that pregnancy/birth complications may be elevated in ADHD and depression in general rather than being directly attributable to medication 1.

Clinical Action Plan

Immediate Steps:

1. Increase bupropion to 300 mg once daily (the standard therapeutic dose for depression/anxiety) 1, 2
2. Reassess symptom response in 2-4 weeks
3. If inadequate response at 300 mg, can consider increasing to maximum 450 mg daily (though data in pregnancy are more limited at this dose) 1

Monitoring During Pregnancy:

• Blood pressure checks (bupropion can elevate BP) 2
• Fetal growth monitoring
• Ensure appropriate maternal weight gain
• Monitor for worsening depression/anxiety symptoms 1

Important Caveats:

• Bupropion is less efficacious than stimulants for ADHD 1, but it's a reasonable option during pregnancy, especially with comorbid depression
• The drug has a favorable side effect profile compared to SSRIs (lower sexual dysfunction risk) 4, 5
• While bupropion has stimulating properties that can occasionally provoke anxiety, clinical trials show it reduces anxiety symptoms in depressed patients with comparable efficacy to SSRIs in mild-to-moderate anxiety 4, 5

At Delivery and Postpartum:

• Maintain therapeutic dose through delivery and breastfeeding 1
• Bupropion is present in breast milk at very low levels; generally no adverse events reported (though 2 case reports of seizures in breastfed infants exist—extremely rare) 1

Bottom Line

Stopping medication now would expose both mother and fetus to the well-documented risks of untreated psychiatric illness while she's only on a subtherapeutic dose. The appropriate response is dose optimization to 300 mg daily, which falls well within established safety parameters for pregnancy and addresses her lack of symptom control 1.