What should you do if someone is depressed while taking Wellbutrin (bupropion)?

Managing Depression in Patients Taking Wellbutrin (Bupropion)

If a patient is experiencing depression while taking Wellbutrin (bupropion), you should assess for medication adherence, dosage adequacy, duration of treatment, side effects, worsening of underlying depression, and emergence of bipolar disorder or other neuropsychiatric symptoms before considering treatment modification.

Initial Assessment

When a patient on Wellbutrin reports depression, conduct a focused evaluation:

• Medication adherence: Verify the patient is taking the medication as prescribed

• Current dosage: Determine if the patient is on an adequate therapeutic dose

  • Standard therapeutic doses: 300-450 mg/day (maximum 450 mg/day) 1
  • Underdosing is a common reason for inadequate response

• Duration of treatment: Confirm if the patient has been on the medication for an adequate trial period (at least 6-8 weeks) 2

• Side effects assessment: Ask about:

  • Sleep disturbances (insomnia is common)
  • Headaches
  • Dry mouth
  • Nausea
  • Anxiety or agitation 2

• Emergence of neuropsychiatric symptoms:

  • Suicidal thoughts or behaviors (especially in first 1-2 months of treatment)
  • Agitation, irritability, hostility
  • Unusual changes in behavior
  • Symptoms of mania/hypomania (elevated mood, decreased need for sleep, racing thoughts) 1

Key Questions to Ask

1. When did the depression symptoms begin or worsen? (Timing relative to starting Wellbutrin)
2. How would you describe your depression symptoms now compared to before starting Wellbutrin?
3. Are you taking the medication exactly as prescribed?
4. Have you experienced any side effects from the medication?
5. Have you had any thoughts of harming yourself?
6. Have you experienced periods of unusually elevated mood, decreased need for sleep, or racing thoughts?

Decision Algorithm

Based on your assessment:

If inadequate response with good adherence:

1. Consider dose adjustment:

   • If current dose is less than 300 mg/day, consider increasing to 300 mg/day
   • Maximum dose should not exceed 450 mg/day due to increased seizure risk 1

2. If already at maximum dose or dose increase not tolerated:

   • Consider switching to another second-generation antidepressant
   • The American College of Physicians recommends selecting antidepressants based on adverse effect profiles, cost, and patient preferences 2

If experiencing side effects:

1. For mild side effects: Reassure that many side effects diminish over time
2. For persistent or severe side effects: Consider dose reduction or medication switch

If signs of bipolar disorder:

1. Discontinue Wellbutrin if mania or hypomania is suspected
2. Refer for psychiatric evaluation for appropriate mood stabilizer treatment 1

If neuropsychiatric symptoms or suicidality:

1. Closely monitor the patient - FDA recommends monitoring beginning 1-2 weeks after initiation of therapy 2
2. Consider discontinuation if symptoms are severe, abrupt in onset, or were not part of the patient's presenting symptoms 1

Important Cautions

• Seizure risk: Bupropion lowers the seizure threshold. Risk increases with doses above 450 mg/day 1
• Hypertension: Monitor blood pressure as bupropion can cause elevated blood pressure 1
• Bipolar disorder: Bupropion, like other antidepressants, can precipitate manic episodes in patients with bipolar disorder 3

Follow-up Recommendations

• Schedule follow-up within 1-2 weeks of any treatment modification
• Assess response to treatment modifications using standardized depression scales
• If no improvement after 6-8 weeks of optimized treatment, consider referral to psychiatry for specialized care 2

Remember that approximately 38% of patients do not achieve a treatment response during 6-12 weeks of treatment with second-generation antidepressants, and 54% do not achieve remission 2. Therefore, treatment modifications or augmentation strategies may be necessary for many patients.