Bupropion Uses in Psychiatry
Bupropion is primarily indicated for the treatment of major depressive disorder (MDD), seasonal affective disorder (SAD), and smoking cessation, with additional off-label uses including ADHD treatment and as an augmentation strategy for partial response to SSRIs. 1, 2
Major Depressive Disorder (MDD)
First-line treatment option for MDD with efficacy comparable to other second-generation antidepressants 2
Particularly beneficial for depression characterized by:
Dosing for MDD:
- Extended-release (XL): 150-300 mg once daily
- Sustained-release (SR): 150 mg twice daily (maximum 400 mg/day)
- Immediate-release: 100-450 mg/day in divided doses 1
Clinical response typically begins within 1-2 weeks with full effect at 4-6 weeks 5
Unique Advantages in Depression Treatment
- Lower sexual dysfunction profile compared to SSRIs like fluoxetine, sertraline, and paroxetine 2
- Does not cause weight gain; may assist with weight management 2
- Activating properties beneficial for depression with low energy/motivation 3
- Only antidepressant with no appreciable serotonergic activity, working primarily through norepinephrine and dopamine pathways 5
Seasonal Affective Disorder (SAD)
- FDA-approved for prevention of seasonal depressive episodes 1
- Treatment initiated in autumn (September-November) before symptom onset
- Continued through winter with taper during first week of spring 1
Smoking Cessation
- Effective for managing nicotine cravings and dependence 6, 7
- Can be used for dual purpose in patients with both depression and tobacco use disorder 5
- Synergistic benefits when used in combination therapy for smoking cessation 7
Augmentation Strategies
- Effective for augmenting partial response to SSRIs/SNRIs 8
- Can address residual symptoms of depression when added to ongoing SSRI therapy 8
- Useful as a second-step treatment after inadequate response to initial antidepressant 2
- Can reverse sexual dysfunction caused by SSRIs/SNRIs 8
Off-Label Uses
- ADHD treatment (evidence is mixed with limited long-term assessments) 7
- Bipolar depression (limited and controversial data on safety/efficacy) 7
- Hypoactive sexual desire disorder 3
- Obesity/weight management 3
Safety Considerations
Contraindications
- Seizure disorders
- Current or prior diagnosis of bulimia or anorexia nervosa
- Abrupt discontinuation of alcohol, benzodiazepines, barbiturates, or antiepileptic drugs
- Concomitant use with MAOIs or within 14 days of MAOI discontinuation 1
Major Adverse Effects
- Seizure risk (dose-dependent, 0.1% at therapeutic doses ≤450 mg/day) 6
- Neuropsychiatric symptoms (anxiety, agitation, insomnia)
- Increased blood pressure and heart rate
- Dry mouth, headache, nausea 6, 5
Special Populations
- Hepatic impairment: Maximum 1 tablet daily
- Renal impairment: Half the normal dose
- Elderly: Consider lower starting doses 6
Monitoring Recommendations
- Assess patient status, therapeutic response, and adverse effects regularly
- Begin monitoring within 1-2 weeks of treatment initiation
- Watch for emergence of agitation, irritability, or unusual behavior changes
- Monitor for increased suicidal thoughts/behaviors, particularly in first 1-2 months 2
- Consider modification of treatment if inadequate response after 6-8 weeks 2
Drug Interactions
- Inhibits CYP2D6, potentially increasing levels of drugs metabolized by this pathway
- Avoid combination with MAOIs due to risk of hypertensive reactions
- Use caution with drugs that lower seizure threshold 1
- May require dose adjustments when used with CYP2B6 inducers (carbamazepine, phenobarbital, phenytoin) 1
Bupropion's unique mechanism of action and side effect profile make it particularly valuable for patients who cannot tolerate serotonergic antidepressants or who have specific symptom profiles like low energy, anhedonia, or concentration difficulties.