What is an appropriate selective serotonin reuptake inhibitor (SSRI) for a patient with anxiety and depression who is currently taking Wellbutrin (bupropion)?

Sertraline is the Most Appropriate SSRI for a Patient with Anxiety and Depression on Wellbutrin

For a patient with anxiety and depression who is currently taking Wellbutrin (bupropion), sertraline is the most appropriate SSRI to add to their regimen. 1

Rationale for Selecting Sertraline

Efficacy for Both Conditions

• Sertraline is a first-line SSRI medication for both anxiety disorders and depression 1
• Starting dose: 25-50 mg daily with target dose up to 200 mg daily 1
• Sertraline has demonstrated comparable efficacy to other SSRIs but with some key advantages in this specific clinical scenario

Compatibility with Bupropion (Wellbutrin)

• Bupropion is a dopamine-norepinephrine reuptake inhibitor that is effective for depression but may have limitations for anxiety 2
• While recent evidence suggests bupropion may not worsen anxiety as previously thought 3, adding an SSRI provides targeted serotonergic action that complements bupropion's mechanism
• The combination of bupropion and sertraline has been specifically studied and shown to be safe and effective 4

Side Effect Profile Considerations

• Sertraline has a favorable side effect profile when combined with bupropion:
  • Less sedation than many other SSRIs 5
  • Bupropion's activating effects can balance sertraline's potential sedative effects
  • Sexual dysfunction from sertraline may be partially mitigated by bupropion 4

Alternative SSRI Options and Why They're Less Optimal

Escitalopram/Citalopram

• While effective and well-tolerated, they have less extensive research specifically in combination with bupropion
• May be considered as second-line options if sertraline is not tolerated

Fluoxetine

• Longer half-life makes dose adjustments more difficult
• Higher potential for drug interactions due to CYP450 inhibition
• Should generally be avoided in older adults due to higher rates of adverse effects 5

Paroxetine

• Higher anticholinergic effects and risk of withdrawal symptoms
• Should generally be avoided in older adults due to higher rates of adverse effects 5
• Higher rates of sexual dysfunction than other SSRIs 5

Implementation Strategy

1. Initial Dosing: Start sertraline at 25-50 mg daily 1
2. Titration: Gradually increase to target dose (up to 200 mg daily) based on response and tolerability
3. Monitoring: Assess at 4 and 8 weeks using standardized instruments for both depression and anxiety 1
4. Side Effect Management:
   • Monitor for common side effects: nausea, diarrhea, headache, insomnia, sexual dysfunction 1
   • Nausea and vomiting are the most common reasons for discontinuation 5

Important Considerations and Cautions

• Duration of Treatment: Continue SSRI for at least 12-24 months after achieving remission 1
• Suicide Risk Monitoring: Especially important during the first 1-2 weeks of treatment 5
• Potential for Serotonin Syndrome: While rare, be vigilant for signs when combining serotonergic agents
• Treatment Resistance: If inadequate response after 6-8 weeks, consider modifying treatment 5

The combination of sertraline with bupropion provides complementary mechanisms of action - bupropion primarily affects dopamine and norepinephrine, while sertraline affects serotonin, creating a balanced approach to treating both depression and anxiety with manageable side effects.