What is the recommended dosing for Wellbutrin (bupropion) in a 14-year-old patient with depression and Attention Deficit Hyperactivity Disorder (ADHD)?

Bupropion Dosing for 14-Year-Old with Depression and ADHD

Bupropion is not FDA-approved for ADHD in adolescents, and should only be considered as a third-line option after failing stimulants and non-stimulant alternatives for a 14-year-old with comorbid depression and ADHD.

Initial Assessment and Treatment Considerations

When considering bupropion for a 14-year-old with depression and ADHD, several important factors must be evaluated:

• Bupropion is primarily approved for depression in adults, not adolescents
• The medication has been studied off-label for ADHD
• The presence of both conditions makes medication selection challenging
• Safety concerns include seizure risk and psychiatric side effects

Recommended Dosing Protocol

If bupropion is selected after failing first-line treatments, follow this dosing protocol:

1. Starting dose: Begin with sustained-release (SR) formulation at 100-150 mg once daily in the morning 1
2. Titration: After 3-7 days, if well tolerated, increase to 150 mg twice daily
3. Maximum dose: Do not exceed 300 mg/day in adolescents (lower than adult maximum of 450 mg/day) 1
4. Administration timing: Give the second dose no later than mid-afternoon to prevent insomnia
5. Monitoring frequency: Weekly for first 4 weeks, then biweekly

Safety Considerations and Monitoring

• Seizure risk: Bupropion lowers seizure threshold; contraindicated with history of seizures or conditions that increase seizure risk 2
• Psychiatric monitoring: Watch for development or worsening of neuropsychiatric symptoms including depression, suicidal ideation/behavior 2
• Vital signs: Regular monitoring of blood pressure and heart rate
• Efficacy assessment: Evaluate both ADHD and depression symptoms using standardized scales
• Discontinuation: If no improvement after 6-8 weeks at therapeutic dose, consider alternative treatment 2

Evidence for Efficacy

Limited evidence supports bupropion use in adolescents with comorbid ADHD and depression:

• A small study (n=24) of adolescents aged 11-16 with comorbid ADHD and depression found that 58% responded to bupropion SR for both conditions 1
• A Cochrane review found low-quality evidence that bupropion decreased ADHD symptom severity in adults 3
• Bupropion has demonstrated efficacy for depression in adults, but data in adolescents is limited 4

Alternative Treatment Options to Consider First

Before using bupropion, consider these FDA-approved options:

1. First-line: Stimulant medications (methylphenidate or amphetamine derivatives) for ADHD, with separate SSRI treatment for depression if needed 2
2. Second-line: Atomoxetine (non-stimulant) at 0.5 mg/kg/day initially, targeting 1.2 mg/kg/day (max 1.4 mg/kg/day or 100 mg) 5
3. Third-line: Alpha-2 agonists (guanfacine/clonidine) if comorbid tics or sleep disturbances are present 5

Important Cautions

• Bupropion carries a black box warning regarding increased risk of suicidal thinking and behavior in children, adolescents, and young adults 2
• Do not combine with MAO inhibitors due to risk of hypertensive reactions 2
• Avoid in patients with eating disorders due to seizure risk
• Maximum daily dose should not exceed 300 mg in adolescents to minimize seizure risk

Bupropion may be particularly useful in this case due to its dual action on both depression and ADHD symptoms, but should be used with caution and close monitoring in this age group.