What medication should a patient with depressive symptoms and a desire to quit smoking be discharged with?

Bupropion is the Optimal Choice for This Patient with Depression and Desire to Quit Smoking

Bupropion should be prescribed for this 21-year-old patient with depressive symptoms and a desire to quit smoking, as it effectively addresses both conditions simultaneously. 1, 2

Rationale for Bupropion Selection

Bupropion is the most appropriate choice for this patient for several key reasons:

1. Dual efficacy for depression and smoking cessation:

   • Bupropion is FDA-approved for both major depressive disorder and as an aid for smoking cessation 2
   • The patient presents with clear depressive symptoms (feeling down, decreased interest in activities, weight loss, insomnia) alongside a desire to quit smoking

2. Evidence-based recommendation:

   • European guidelines on cardiovascular disease prevention specifically recommend bupropion as one of the first-line pharmacological aids for smoking cessation 1
   • Bupropion has consistently improved quit rates compared to unassisted attempts 3

3. Appropriate for patient profile:

   • The patient's depressive symptoms make bupropion particularly suitable as it can address both the mood disorder and smoking cessation simultaneously 4
   • The patient is young (21) with no mentioned contraindications to bupropion therapy

Dosing and Administration

• Initial dosing: Start with 150 mg once daily for the first 4 days 2
• Target dose: Increase to 300 mg once daily after 4 days 2
• Timing: Begin bupropion 1-2 weeks before the target quit date to allow the medication to reach therapeutic levels 1
• Duration: Continue treatment for at least 7-12 weeks for optimal smoking cessation outcomes

Monitoring and Follow-up

• Schedule follow-up within one month and monthly thereafter for 4 months 1
• Monitor for:
  • Blood pressure and heart rate, especially in the first 12 weeks 5
  • Neuropsychiatric symptoms including worsening depression, suicidal ideation (particularly important given the patient's age) 2
  • Efficacy in reducing cigarette cravings and maintaining abstinence
  • Common side effects: insomnia, dry mouth, anxiety/jitteriness 2

Why Not the Other Options?

1. Escitalopram (Option B):

   • SSRIs like escitalopram have not shown significant efficacy for smoking cessation 3
   • While it would address depression, it would not provide the dual benefit for smoking cessation

2. Varenicline (Option C):

   • While effective for smoking cessation 6, varenicline has been associated with neuropsychiatric adverse events including depression and suicidal ideation 2
   • Given the patient's existing depressive symptoms, varenicline poses unnecessary risks

3. Nicotine patches (Option D):

   • While effective for smoking cessation, nicotine replacement therapy does not address the patient's depressive symptoms
   • Evidence suggests bupropion is comparable in efficacy to nicotine replacement therapy for smoking cessation 3

Important Considerations and Cautions

• Seizure risk: Bupropion lowers seizure threshold; assess for history of seizure disorders 2
• Suicidality monitoring: Young adults (under 24) have increased risk of suicidal thoughts with antidepressants; monitor closely 2
• Contraindications: Avoid in patients with seizure disorders, eating disorders, or those taking MAOIs 2
• Patient education: Inform the patient that:
  • Full antidepressant effects may take 2-4 weeks
  • Smoking cessation benefits typically begin within 1-2 weeks
  • Common side effects include insomnia, dry mouth, and headache
  • Report any worsening depression or suicidal thoughts immediately

Bupropion represents the optimal choice for this patient as it effectively addresses both the depressive symptoms and smoking cessation needs with a single medication, supported by strong clinical evidence and guidelines.