What mood stabilizer can be added to Wellbutrin (bupropion) for Attention Deficit Hyperactivity Disorder (ADHD) and depression?

Mood Stabilizer Options for Combination with Wellbutrin for ADHD and Depression

For patients with ADHD and depression who are currently on Wellbutrin (bupropion), lamotrigine is the preferred mood stabilizer to add due to its superior efficacy for depressive symptoms and favorable side effect profile.

Understanding the Clinical Context

When considering adding a mood stabilizer to Wellbutrin for patients with ADHD and depression, several factors must be considered:

1. Wellbutrin (bupropion) is effective for both depression and ADHD symptoms
2. The mood stabilizer should complement Wellbutrin's effects without increasing side effects
3. The combination should address both conditions while minimizing risks

Mood Stabilizer Options

First-Line Option: Lamotrigine

• Most effective for preventing depressive episodes among mood stabilizers 1
• Minimal drug interactions with bupropion
• Does not cause weight gain or cognitive dulling
• Particularly beneficial for bipolar II patients with predominant depressive symptoms
• Dosing: Start at 25mg daily, increase by 25mg weekly to target dose of 100-200mg daily

Second-Line Option: Lithium

• Strong evidence for prophylaxis of mood episodes 1
• Lithium-bupropion combination can provide effective prevention of both mania and depression
• Requires regular monitoring of lithium levels, thyroid and renal function 2
• Baseline labs should include CBC, thyroid function, BUN, creatinine, and serum calcium 2
• Monitor lithium levels, renal and thyroid function every 3-6 months

Third-Line Option: Valproate

• Effective for mania and mood stabilization
• May improve symptoms in rapid cycling 1
• Requires monitoring of liver function, CBC, and drug levels
• Caution in women of childbearing age due to teratogenicity and risk of polycystic ovary disease 2

Important Considerations

Safety Monitoring

• When combining mood stabilizers with bupropion, start with modest doses and increase slowly to reduce risk of toxic interactions 3
• Monitor for neuropsychiatric adverse effects, particularly in patients under 24 years 2
• Bupropion may lower seizure threshold - use caution with other medications that affect seizure threshold 2

Efficacy for ADHD

• Bupropion alone has demonstrated efficacy for ADHD symptoms (SMD -0.50,95% CI -0.86 to -0.15) 4
• An open trial of bupropion in adults with ADHD and bipolar disorder showed significant reduction in ADHD symptoms without activation of mania 5
• The combination of mood stabilizer and bupropion may allow for lower doses of each medication, reducing side effects 1

Special Populations

• For patients with bipolar disorder and ADHD, mood symptoms should be stabilized with mood stabilizers before addressing residual ADHD symptoms 6
• For patients with rapid cycling, lamotrigine has shown efficacy in reducing cycling, particularly in bipolar II patients 1

Implementation Strategy

1. Start with lamotrigine at 25mg daily
2. Titrate slowly (25mg weekly increases) to minimize risk of Stevens-Johnson syndrome
3. Target dose of 100-200mg daily based on response
4. Monitor for rash, headache, and other side effects
5. Assess response after 6-8 weeks at therapeutic dose

Potential Pitfalls

• Failure to recognize bipolar disorder in patients with ADHD and depression
• Inadequate titration of lamotrigine (too rapid increases risk rash)
• Overlooking the need for regular monitoring with lithium or valproate
• Not addressing sleep issues that may be exacerbated by bupropion

By following this approach, the combination of Wellbutrin with an appropriate mood stabilizer can effectively address both ADHD and depression while minimizing risks and side effects.