Uses of Wellbutrin (Bupropion) in Psychiatry
Wellbutrin (bupropion) is primarily used for the treatment of major depressive disorder (MDD) and seasonal affective disorder (SAD), with additional off-label applications in smoking cessation and as an augmentation strategy for partial response to other antidepressants.
Primary FDA-Approved Indications
Major Depressive Disorder (MDD)
- Bupropion is indicated for the treatment of major depressive disorder as defined by the Diagnostic and Statistical Manual (DSM) 1
- Available as three formulations with different dosing schedules:
- Immediate release (IR): administered three times daily
- Sustained release (SR): administered twice daily
- Extended/modified release (XL/XR): administered once daily 2
- Starting dose is typically 150 mg once daily, which may be increased to 300 mg once daily after 4 days 1
Seasonal Affective Disorder (SAD)
- FDA-approved for the prevention of seasonal major depressive episodes in patients with SAD 1
- Treatment should be initiated in autumn before symptom onset and continued through winter 1
- Recommended starting dose is 150 mg once daily, which may be increased to 300 mg after 7 days 1
- Should be tapered in early spring by decreasing to 150 mg once daily before discontinuation 1
Unique Characteristics Among Antidepressants
Mechanism of Action
- Presumed to be a dopamine-norepinephrine reuptake inhibitor, distinguishing it from SSRIs 3, 2
- May increase activity of vesicular monoamine transporter-2, which transports dopamine, norepinephrine, and serotonin into presynaptic vesicles 3
Side Effect Profile Advantages
- Associated with a lower rate of sexual adverse events compared to many other antidepressants, particularly fluoxetine and sertraline 4
- Less likely to cause weight gain compared to some tricyclic antidepressants 2
- Less somnolence than many other antidepressants 2
Common Side Effects and Monitoring
- Most common side effects include nervousness, insomnia, dry mouth, headache, and decreased appetite 5, 3
- May increase blood pressure and heart rate, requiring regular monitoring of vital signs, especially during the first 12 weeks of treatment 5
- Lowers seizure threshold - contraindicated in patients with seizure disorders 5
- Requires monitoring for suicidal thoughts and behaviors, particularly in patients younger than 24 years 5, 1
Additional Clinical Applications
Smoking Cessation
- Effective for tobacco cessation, increasing long-term smoking abstinence rates by 69% compared to placebo 5
- Increases cessation rates at 6+ months compared to placebo (19.7% vs 11.5%) 5
Augmentation Strategy
- Useful in augmenting partial response to selective serotonin reuptake inhibitors (SSRIs) 3
- Low-quality evidence showed no difference in response or remission when switching from one SGA to bupropion compared with switching to cognitive therapy 4
Important Precautions
- Should not be combined with monoamine oxidase inhibitors (MAOIs) 5, 3
- Tablets should be swallowed whole, not crushed, divided, or chewed 1
- Gradual dose increase is recommended to minimize seizure risk 1
- Requires close monitoring for emergence of anxiety, agitation, or unusual changes in behavior 5
Bupropion provides clinicians with a valuable option in the antidepressant armamentarium, particularly for patients concerned about sexual dysfunction or sedation with other antidepressants, and for those who may benefit from its dual action on both depression and smoking cessation.