Is bupropion (Wellbutrin) effective for treating sleep disorders?

Bupropion is Not Effective for Treating Sleep Disorders and May Worsen Insomnia

Bupropion (Wellbutrin) is not recommended for treating sleep disorders and can actually worsen insomnia due to its activating effects. 1, 2

Mechanism and Effects on Sleep

Bupropion has activating properties that can negatively impact sleep:

• The FDA drug label specifically lists insomnia as a common adverse effect, occurring in 11-16% of patients taking bupropion 1
• Bupropion is classified as an "activating antidepressant" that can worsen sleep, with many patients requiring co-prescription of sleep-promoting agents 2
• Unlike sedating antidepressants (doxepin, mirtazapine, trazodone), bupropion has stimulant-like properties that can interfere with normal sleep architecture

First-Line Treatments for Sleep Disorders

Current guidelines strongly recommend other approaches for sleep disorders:

1. Cognitive Behavioral Therapy for Insomnia (CBT-I) is the first-line treatment for chronic insomnia disorder 3, 4

   • More effective than pharmacotherapy for both short-term and long-term outcomes
   • Includes components such as sleep restriction, stimulus control, and cognitive restructuring

2. FDA-approved medications for insomnia when pharmacotherapy is indicated:

   • For sleep onset insomnia: zolpidem, zaleplon, ramelteon 4
   • For sleep maintenance insomnia: doxepin (3-6mg), eszopiclone, suvorexant 4
   • Low-dose melatonin (1-3mg) can be considered as a safer first option 4

Special Considerations

While bupropion is generally contraindicated for sleep disorders, there are rare specific clinical scenarios where it might be considered:

• In cases of narcolepsy with comorbid depression, bupropion has shown some benefit in reducing sleepiness and normalizing REM sleep patterns in case reports 5
• For patients with periodic limb movement disorder (PLMD) and depression, bupropion SR has been shown to reduce periodic limb movements associated with arousals from sleep 6
• In severe morning sleep inertia, bedtime long-acting bupropion has been used successfully in limited case reports 7

Clinical Pitfalls to Avoid

• Do not prescribe bupropion for general insomnia treatment, as it will likely worsen sleep problems
• Be aware that insomnia is one of the most common side effects of bupropion, occurring in up to 16% of patients 1
• Patients already taking bupropion who develop sleep problems may need dosing adjustments (morning administration rather than evening) or addition of a sleep-promoting agent
• Recognize that bupropion can alter REM sleep architecture, which may be beneficial in specific conditions but detrimental in primary insomnia 8

For patients with insomnia requiring pharmacologic treatment, evidence-based guidelines recommend starting with CBT-I and considering medications like doxepin, ramelteon, or low-dose melatonin before resorting to more potent sedative-hypnotics 3, 4.