Medication-Related Symptoms: Crying Spells, Mood Swings, and Irritability
The combination of Abilify (aripiprazole) 20mg, Wellbutrin (bupropion) XL 150mg, and Modafinil 200mg is likely causing the patient's symptoms of crying spells, mood swings, increased irritability, emotional sensitivity, and increased fatigue due to drug interactions and side effects.
Medication Analysis and Likely Causes
Modafinil (200mg)
- The FDA drug label for Modafinil indicates that psychiatric symptoms are common adverse effects 1:
- Anxiety (1%)
- Nervousness (1%)
- Insomnia (<1%)
- Confusion (<1%)
- Agitation (<1%)
- Depression (<1%)
- Emotional lability (1%)
- Modafinil can cause irritability and mood changes that align with the patient's symptoms 1
Bupropion (Wellbutrin XL 150mg)
- Can cause emotional disturbances, particularly at higher doses
- Associated with dose-related risk of manic symptoms in bipolar patients 2
- Can cause irritability and agitation as side effects 3
Aripiprazole (Abilify 20mg)
- While generally well-tolerated compared to other antipsychotics, it can cause akathisia (restlessness) that may present as irritability 4
- High dose (20mg) may be contributing to the emotional symptoms
Drug Interaction Analysis
The combination of these three medications likely creates a problematic interaction:
Serotonergic and Dopaminergic Overlap:
- Modafinil increases dopamine and has some serotonergic effects
- Bupropion increases dopamine and norepinephrine
- Aripiprazole is a partial dopamine agonist
- This combination may create an imbalance in neurotransmitter systems 3
Risk of Serotonin Syndrome:
- While full serotonin syndrome is not evident, milder forms may present with irritability and mood changes 3
- Multiple serotonergic medications increase this risk
Emotional Blunting Effect:
- Antidepressants can cause emotional blunting in up to 46% of patients 5
- This can manifest as crying spells and emotional sensitivity as the brain attempts to "break through" the blunting
Management Recommendations
Based on the patient's symptoms and medication profile, I recommend reducing or discontinuing Modafinil as the first intervention, as it is most likely contributing to the emotional symptoms.
Follow this algorithm:
First step: Discontinue Modafinil 200mg
- Modafinil is most likely contributing to irritability, mood swings, and emotional lability 1
- Reassess after 1-2 weeks off Modafinil
If symptoms persist: Consider reducing Abilify dose
- Reduce from 20mg to 15mg or 10mg
- High-dose Abilify may be contributing to akathisia-like symptoms presenting as irritability
If still symptomatic: Evaluate Wellbutrin
- Consider switching to an SSRI if appropriate for the patient's condition
- Bupropion can cause irritability and agitation in some patients 3
Monitoring and Follow-up
- Schedule follow-up within 1-2 weeks after medication changes
- Monitor specifically for:
- Changes in crying spells frequency
- Mood stability
- Irritability levels
- Energy levels
- Sleep quality
Important Considerations
- Emotional symptoms may be dose-related: Several studies suggest that emotional side effects from these medications are dose-dependent 2, 6
- Fatigue may worsen initially: Be aware that discontinuing Modafinil may temporarily worsen fatigue before emotional symptoms improve
- Avoid abrupt discontinuation: Consider tapering Modafinil over several days to minimize withdrawal effects
Common Pitfalls to Avoid
- Mistaking medication side effects for worsening depression: The crying spells and emotional sensitivity are likely medication-induced rather than worsening of underlying condition
- Adding more medications: Resist the urge to add another medication to treat these side effects
- Discontinuing all medications simultaneously: This could lead to withdrawal and symptom rebound
The patient's symptoms strongly suggest medication side effects rather than disease progression, with Modafinil being the most likely culprit given its known psychiatric side effect profile.