Could I try a different medication to manage my anxiety, anger, and irritability while taking Wellbutrin (bupropion) and Prozac (fluoxetine)?

Managing Anxiety, Anger, and Irritability While on Wellbutrin and Prozac

You should consider switching to a different antidepressant medication, as bupropion (Wellbutrin) can worsen anxiety, irritability, and anger in some patients, particularly when combined with fluoxetine (Prozac).

Understanding Your Current Medication Issues

Bupropion (Wellbutrin) is known to have an activating effect that can exacerbate anxiety and irritability in some patients. The FDA label specifically warns that bupropion can cause "anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia, and other unusual changes in behavior" 1.

Your current symptoms align with these known side effects:

• Increased anxiety ("through the roof")
• Worsened anger and irritability

Medication Options to Consider

First-Line Options:

1. SSRI Monotherapy:

   • Sertraline (Zoloft): 25-50mg daily initially, maximum 200mg daily
     • Well tolerated with less effect on metabolism of other medications 2
   • Citalopram (Celexa): 10mg daily initially, maximum 40mg daily
     • Well tolerated though some patients experience nausea and sleep disturbances 2

2. SNRI Option:

   • Venlafaxine: 37.5mg daily initially, maximum 225mg daily
     • Effective for both anxiety and depression 3
     • Requires blood pressure monitoring at higher doses

Second-Line Options:

1. Mirtazapine (Remeron): 7.5mg at bedtime initially, maximum 30mg at bedtime

   • Promotes sleep and appetite while treating anxiety and depression 2
   • Less likely to cause activation or agitation

2. Paroxetine (Paxil): 10mg daily initially, maximum 40mg daily

   • Less activating than other SSRIs but has more anticholinergic effects 2

Why Your Current Regimen May Be Problematic

Bupropion is described in guidelines as "activating" with a "possible rapid improvement of energy level" and "should not be used in agitated patients" 2. This activating effect may be contributing to your anxiety and irritability.

When combined with fluoxetine (Prozac), which is also described as "activating" with a "very long half-life" 2, this combination may be intensifying your symptoms.

Research shows that approximately one-third of depressed patients experience "anger attacks" - sudden spells of anger accompanied by autonomic activation symptoms 4, 5. These symptoms often respond well to serotonergic antidepressants.

Recommended Approach

1. Discontinuation Strategy:

   • Gradually taper off bupropion first under medical supervision
   • Consider whether to maintain fluoxetine or switch to another SSRI/SNRI

2. Medication Switch:

   • Consider sertraline as a first-line alternative due to its favorable side effect profile
   • Start at a low dose (25-50mg) and titrate gradually

3. Monitoring:

   • Watch for improvement in anxiety, anger, and irritability symptoms
   • Be aware that medication changes may take 4-6 weeks for full effect

Important Considerations

• Avoid benzodiazepines for long-term management as they can cause behavioral disinhibition in some patients 6
• Never abruptly discontinue your current medications as this can cause withdrawal symptoms
• Regular follow-up is essential to monitor response and adjust treatment as needed

Studies have shown that 53-71% of depressed patients with anger attacks respond to appropriate antidepressant treatment 5, and SSRIs that affect serotonergic neurotransmission may be particularly effective for managing anger and irritability 7.

By addressing these medication issues, you have a good chance of finding relief from your current symptoms of anxiety, anger, and irritability.