What medication can be added to treat a patient with a mood disorder?

Bupropion is the Optimal Medication to Add for a Patient with Mood Disorder

For a patient with a mood disorder, bupropion is the most appropriate medication to add, offering effective treatment with fewer side effects such as sexual dysfunction compared to other antidepressants. 1, 2

Rationale for Choosing Bupropion

Bupropion offers several advantages as an augmentation strategy for mood disorders:

• Acts through a unique mechanism as a norepinephrine-dopamine reuptake inhibitor
• Lower risk of sexual dysfunction compared to SSRIs
• Less likely to cause sedation or weight gain
• Effective for both unipolar depression and bipolar depression
• Can be used as augmentation to existing antidepressant therapy

Dosing and Administration

• Starting dose: 150 mg once daily of extended-release formulation
• Target dose: 300 mg once daily
• After 4 days, may increase to 300 mg once daily if tolerated 3
• Maximum recommended dose: 450 mg daily (do not exceed this dose, especially in bipolar disorder) 4
• Available in three formulations:
  • Immediate release (IR): administered three times daily
  • Sustained release (SR): administered twice daily
  • Extended release (XL): administered once daily 5

Monitoring and Precautions

Key Warnings

• Seizure risk: Dose-related; limit daily dose to 450 mg and increase gradually 3
• Activation of mania/hypomania: Screen for bipolar disorder before initiating 3
• Neuropsychiatric symptoms: Monitor for agitation, anxiety, and other mood changes 3
• Blood pressure: Monitor before and during treatment as bupropion can increase blood pressure 3

Common Side Effects

• Dry mouth, nausea, insomnia, dizziness, agitation, anxiety, tremor 3
• Less likely to cause sexual dysfunction or weight gain than SSRIs 2

Special Considerations

Drug Interactions

• CYP2D6 inhibition: Bupropion inhibits CYP2D6 and can increase concentrations of:

  • Antidepressants (venlafaxine, nortriptyline, imipramine, paroxetine, fluoxetine, sertraline)
  • Antipsychotics (haloperidol, risperidone)
  • Beta-blockers (metoprolol)
  • Type 1C antiarrhythmics 3

• Contraindicated with:

  • MAOIs (allow 14 days between stopping MAOIs and starting bupropion)
  • Seizure disorders
  • Current or prior diagnosis of bulimia or anorexia nervosa
  • Abrupt discontinuation of alcohol, benzodiazepines, or barbiturates 3

Combination Strategies

• Bupropion can be effectively combined with SSRIs or SNRIs for treatment-resistant depression 6, 7
• When combined with venlafaxine, significant reduction in depressive symptoms has been observed in treatment-resistant cases 6
• The combination of escitalopram and bupropion-SR has shown high response rates (62%) and remission rates (50%) 7

Evidence for Bipolar Depression

• Bupropion has shown efficacy in bipolar depression with potentially lower risk of inducing switches to hypomania or mania 4
• In difficult-to-treat bipolar depression, 8 of 13 patients showed >50% reduction in depression scores within 4 weeks when bupropion was added to mood stabilizers 4
• When treating bipolar depressed patients, do not exceed 450 mg daily to minimize switch risk 4

Clinical Decision Algorithm

1. If patient has unipolar depression: Start bupropion at 150 mg daily, titrate to 300 mg daily after 4 days
2. If patient has bipolar disorder: Ensure patient is on a mood stabilizer before adding bupropion
3. If patient is on other antidepressants: Bupropion can be added as augmentation therapy
4. If patient has concerns about sexual dysfunction: Bupropion is preferred over SSRIs
5. If patient has seizure history: Consider alternative medication as bupropion lowers seizure threshold

By following this evidence-based approach, bupropion offers an effective option for augmenting treatment in patients with mood disorders while minimizing common side effects associated with other antidepressants.