What is the best treatment option for a 33-year-old female with generalized anxiety disorder and depression, who has gained significant weight and has previously tried Celexa (citalopram), Wellbutrin (bupropion), and Prozac (fluoxetine)?

Treatment Options for a 33-Year-Old Female with GAD, Depression, and Weight Gain

Bupropion is the most appropriate treatment option for this patient with generalized anxiety disorder, depression, and weight gain who has previously tried Celexa, Wellbutrin, and Prozac. 1

Rationale for Bupropion Selection

• Bupropion is strongly recommended for patients with depression who have concerns about weight gain, as it is associated with modest weight loss rather than weight gain 2, 3
• The American College of Physicians guidelines support bupropion as an effective second-generation antidepressant for major depressive disorder 1
• For patients who have experienced weight gain on previous antidepressants (like this patient has), switching to a medication with a low risk of weight gain such as bupropion is recommended 3
• The patient's previous trial of Wellbutrin (bupropion) should be reassessed for adequate dosing, duration, and adherence, as it remains the best option for her clinical presentation 1

Medication Considerations for Weight Management

• Most antidepressants have varying risks of weight gain, with significant within-class differences 2
• Bupropion demonstrates weight-loss effects, making it particularly suitable for this patient who has already gained 14 pounds in five months 2, 3
• SSRIs like Celexa (citalopram) and Prozac (fluoxetine) that the patient has previously tried can cause weight gain in some patients 4
• The GUIDED study showed that patients on high-risk medications for weight gain were significantly more likely to experience clinically significant weight gain (≥3%) at both 12 weeks (29.3% vs. 16.3%) and 24 weeks (33.5% vs. 23.5%) 5

Dosing and Administration

• Bupropion should be initiated at a low dose and gradually titrated to minimize side effects 6
• For depression, the typical starting dose is 150 mg once daily, which can be increased to 300 mg daily (150 mg twice daily) after several days if well tolerated 6
• Maximum recommended dose is 450 mg daily, divided into multiple doses 6
• The medication should be taken in the morning to minimize insomnia 6

Potential Side Effects and Monitoring

• Common side effects include insomnia (16%), dizziness (11%), agitation (9%), anxiety (6%), and headache 6
• Bupropion has a lower rate of sexual adverse events compared to SSRIs like fluoxetine and sertraline 1
• Monitor for central nervous system stimulation, which occurs in 1-2% of patients 6
• Regular follow-up is recommended to assess response and manage any side effects 1

Alternative Options if Bupropion is Ineffective or Contraindicated

• Combination therapy with topiramate could be considered, as it is consistently associated with weight loss and may help with mood stabilization 7
• SNRIs like venlafaxine have shown efficacy in treating both GAD and depression, though they may have a neutral to slightly positive effect on weight 8
• Cognitive behavioral therapy (CBT) is recommended by the American College of Physicians as equally effective to second-generation antidepressants and should be strongly considered as an alternative or adjunctive treatment 1

Important Clinical Considerations

• If the patient previously tried Wellbutrin (bupropion) without success, it's important to evaluate whether the dosage was adequate, the duration of treatment was sufficient, and if there were any adherence issues 1
• Bupropion is contraindicated in patients with seizure disorders, current or prior diagnosis of bulimia or anorexia nervosa, or those undergoing abrupt discontinuation of alcohol or sedatives 6
• The medication should be used with caution in patients with a history of seizures, cranial trauma, or other factors that lower the seizure threshold 6
• Regular monitoring of weight and mental health symptoms is essential to evaluate treatment effectiveness 1