What is the best approach to manage a patient with anxiety and seasonal affective disorder already on Prozac (fluoxetine) 10mg daily, considering the potential addition of Wellbutrin (bupropion) for increased energy and motivation?

Management of Anxiety and Seasonal Affective Disorder with Fluoxetine and Bupropion

Bupropion is an excellent addition to fluoxetine for a patient with anxiety and seasonal affective disorder who requires increased energy and motivation, as it has FDA approval for seasonal affective disorder prevention and complements fluoxetine's anxiolytic effects. 1, 2

Current Medication Assessment

• Fluoxetine (Prozac) 10mg daily:
  • Currently at a subtherapeutic dose for both anxiety and depression
  • Standard therapeutic dose range is 20-80mg daily
  • May need dose optimization before adding another agent

Rationale for Adding Bupropion

1. Strong evidence for SAD: Bupropion XL has FDA approval specifically for prevention of seasonal affective disorder 1

   • Clinical trials showed 44% relative risk reduction in SAD recurrence compared to placebo 2
   • Demonstrated efficacy in preventing autumn-winter depressive episodes

2. Complementary mechanism of action:

   • Fluoxetine: Primarily serotonergic (SSRI)
   • Bupropion: Primarily dopaminergic and noradrenergic
   • This combination addresses both mood and energy/motivation concerns

3. Energy and motivation benefits:

   • Bupropion's dopaminergic effects specifically target energy, motivation, and concentration issues 3
   • Avoids the sedation sometimes associated with SSRIs alone

Implementation Plan

1. Optimize fluoxetine first:

   • Increase fluoxetine to 20mg daily for 2-4 weeks
   • Assess response and side effects before adding bupropion

2. Add bupropion:

   • Start with bupropion XL 150mg once daily in the morning 1
   • After 7 days, may increase to target dose of 300mg once daily if tolerated
   • Morning administration is important to avoid insomnia

3. Monitoring schedule:

   • Evaluate at 2 weeks for initial side effects and adjustment
   • Complete evaluation at 4-6 weeks to assess response 3
   • Use standardized measures (GAD-7 for anxiety, PHQ-9 for depression) to track progress

Important Precautions

• Seizure risk: Bupropion lowers seizure threshold; increase dose gradually 1

  • Contraindicated in patients with seizure disorders
  • Avoid in patients with eating disorders or those taking other medications that lower seizure threshold

• Drug interactions:

  • Monitor for serotonin syndrome with this combination
  • Bupropion inhibits CYP2D6, which metabolizes fluoxetine
  • May need to adjust fluoxetine dose if side effects emerge

• Anxiety exacerbation:

  • Bupropion can sometimes worsen anxiety in sensitive individuals
  • If anxiety increases, consider slowing titration or reducing dose

Alternative Approaches

If this combination is not effective or not tolerated:

1. Light therapy: 2,500-10,000 lux for 30-60 minutes daily is effective for SAD 4

   • Can be used alongside pharmacotherapy
   • Best administered in the morning

2. Alternative medication options:

   • Venlafaxine (SNRI) may be beneficial for combined anxiety and depression 3
   • Sertraline has favorable side effect profile and efficacy for both conditions 3

Lifestyle Recommendations

• Increase exposure to natural light
• Regular physical exercise, particularly outdoors in daylight
• Maintain consistent sleep schedule
• Consider cognitive behavioral therapy (CBT) which has evidence for both anxiety and SAD 3, 4

Regarding Supplements

• Limited evidence for supplements mentioned (CBD, THC, saffron, ginkgo biloba)
• Recommend focusing on evidence-based pharmacotherapy and lifestyle interventions first
• If patient wishes to continue supplements, monitor for potential interactions with prescribed medications

The combination of fluoxetine and bupropion provides comprehensive coverage for both the anxiety and seasonal components of the patient's presentation, with particular attention to the energy and motivation concerns.