Wellbutrin (Bupropion) for Anxiety Disorders
Wellbutrin (bupropion) is not recommended as a first-line treatment for anxiety disorders due to lack of sufficient evidence supporting its efficacy and concerns about potentially exacerbating anxiety symptoms. 1
Evidence Assessment
Guidelines and Recommendations
The Japanese Society of Anxiety and Related Disorders/Japanese Society of Neuropsychopharmacology clinical practice guideline (2023) does not include bupropion among recommended treatments for anxiety disorders. Instead, the guideline specifically recommends:
- SSRIs and SNRIs as first-line pharmacotherapy for social anxiety disorder due to:
- High treatment response rates (NNT = 4.70 for SSRIs, NNT = 4.94 for SNRIs)
- Acceptable safety profiles with dropout rates similar to placebo 1
Bupropion is categorized among "other antidepressants" that have not been adequately studied for anxiety disorders and thus are not included in treatment recommendations 1.
Research Evidence
Limited research on bupropion for anxiety shows mixed results:
A small 2008 pilot study comparing bupropion XL with escitalopram in generalized anxiety disorder suggested comparable anxiolytic efficacy, but the sample size was very small (n=24) and requires further research 2
A 2003 open-label study of bupropion SR in panic disorder showed some improvement in symptoms, but the open-label design limits the strength of these findings 3
A 2023 naturalistic study using propensity matching found no significant differences in anxiety outcomes between those prescribed SSRIs versus bupropion across 12 weeks of treatment, challenging the traditional belief that bupropion exacerbates anxiety 4
However, a 2008 pooled analysis of 10 studies found a modest advantage for SSRIs compared to bupropion in treating depression with high anxiety levels (anxious depression), with 6% higher response rates for SSRIs 5
Treatment Approach for Anxiety Disorders
First-line Treatments
SSRIs (fluvoxamine, paroxetine, sertraline, escitalopram, citalopram, fluoxetine)
- Demonstrated high response rates with NNT = 4.70
- Similar dropout rates to placebo 1
SNRIs (primarily venlafaxine)
- Response rate similar to SSRIs (NNT = 4.94)
- Similar safety profile to SSRIs 1
Common Side Effects to Monitor
- Neuropsychiatric: somnolence, dizziness
- Gastrointestinal: nausea
- Serious (rare): serotonin syndrome, neuroleptic malignant syndrome 1
Clinical Considerations
When Bupropion Might Be Considered
Despite not being first-line for anxiety disorders, bupropion might be considered in specific scenarios:
- Patients who have failed multiple SSRI/SNRI trials
- Patients who cannot tolerate the sexual side effects of SSRIs/SNRIs
- Patients with comorbid ADHD or smoking cessation needs 6
Monitoring and Cautions
If bupropion is used despite limited evidence:
- Monitor for worsening anxiety, especially in early treatment
- Be aware of contraindications including seizure disorders, eating disorders, and use with MAOIs 1
- Common side effects include headache, nausea, anxiety, insomnia, and constipation 1
Conclusion
Based on current guidelines and evidence, SSRIs and SNRIs remain the recommended pharmacological treatments for anxiety disorders, while bupropion lacks sufficient evidence to support its use as a primary treatment for anxiety. The most recent and highest quality evidence (2023 Japanese guideline) does not include bupropion among recommended treatments for anxiety disorders due to inadequate study evidence 1.