Switching from Escitalopram to Wellbutrin (Bupropion)
The safest approach is a cross-taper strategy: start bupropion SR at 150 mg once daily while maintaining your current escitalopram dose, increase bupropion to 150 mg twice daily after 3 days, then gradually taper escitalopram over 1-2 weeks. 1
Cross-Taper Protocol
Begin bupropion SR at 150 mg once daily in the morning while continuing your full escitalopram dose. 1 This allows the new medication to reach therapeutic levels before discontinuing the SSRI, minimizing the risk of depressive relapse during the transition. 2
After 3 days on bupropion 150 mg daily, increase to the target dose of 150 mg twice daily (300 mg total daily). 1 Take the second dose before 3 PM to minimize insomnia risk. 3, 1
Once bupropion reaches 300 mg daily and is well-tolerated, begin tapering escitalopram by reducing the dose by 50% for one week, then discontinuing. 2 Gradual tapering over days to weeks reduces withdrawal syndrome risk and severity. 2
Critical Timing Considerations
Do not abruptly stop escitalopram, as this can cause withdrawal symptoms including dizziness, nausea, headache, and mood changes. 2 The cross-taper approach prevents both SSRI withdrawal and gaps in antidepressant coverage that could trigger depressive relapse. 2
Conservative switching strategies that involve complete washout periods between medications can take weeks and include periods without treatment, risking potentially life-threatening exacerbations of depression. 2 The cross-taper avoids this pitfall while maintaining safety.
Contraindications to This Switch
Absolutely avoid bupropion if you have a seizure disorder, history of seizures, eating disorder (anorexia or bulimia), or are abruptly discontinuing alcohol or benzodiazepines. 1 Bupropion lowers seizure threshold, with risk increasing at doses above 450 mg daily. 3, 4
Do not use bupropion within 14 days of stopping a monoamine oxidase inhibitor (MAOI), as this combination can cause hypertensive crisis. 1
Exercise caution if you have uncontrolled hypertension, as bupropion can elevate blood pressure. 1
Dose Adjustments for Special Populations
For older adults, start bupropion at 37.5 mg daily and increase by 37.5 mg every 3 days to a maximum of 150 mg twice daily. 3, 1 This represents approximately 50% of the standard starting dose. 1
For patients with moderate to severe hepatic impairment, do not exceed 150 mg total daily dose of bupropion. 1
For patients with moderate to severe renal impairment, reduce the total daily bupropion dose by half. 1
Expected Side Effects and Management
Common bupropion side effects include insomnia, dry mouth, headache, nervousness, tremors, and nausea. 3, 1 These are typically mild and often resolve within 1-2 weeks. 3
Insomnia is the most common complaint—taking the second dose before 3 PM significantly reduces this risk. 3, 1 If insomnia persists, consider reducing the afternoon dose or switching to once-daily dosing at 150 mg. 3
Bupropion tends to be activating and may reduce apathy, making it particularly useful for patients with low energy depression. 3 However, do not use bupropion in highly agitated patients, as it can worsen agitation. 3
Monitoring During Transition
Schedule a follow-up visit within 2 weeks of initiating the switch to assess efficacy, side effects, and adherence. 3, 1 This early check-in allows for dose adjustments before problems escalate.
Monitor blood pressure at follow-up visits, particularly in patients with pre-existing hypertension. 1
Monitor closely for neuropsychiatric adverse effects, especially in patients younger than 24 years, including worsening depression, suicidal ideation, or unusual behavioral changes. 3, 1 While uncommon, these warrant immediate discontinuation if they occur. 3
Efficacy Timeline and Next Steps
A full therapeutic trial requires 4-8 weeks at the target dose before determining efficacy. 3, 1 Some patients may experience rapid improvement in energy levels within the first 1-2 weeks due to bupropion's activating properties. 3
If no response is seen after 6-8 weeks at an adequate bupropion dose (300 mg daily), consider switching to a different antidepressant or augmentation strategy. 1 Evidence from the STAR*D trial shows that switching between different antidepressant classes (including switching to bupropion) produces similar remission rates of approximately 25-30%. 3
Common Pitfalls to Avoid
Never exceed 450 mg total daily dose of bupropion, as seizure risk increases substantially above this threshold. 1, 4 One case report documented mania occurring only after exceeding 450 mg daily in a patient with bipolar disorder, suggesting dose-related toxicity. 4
Do not take bupropion late in the day—this is the most common cause of treatment-limiting insomnia. 1
Do not abruptly stop escitalopram without a taper, even when starting bupropion. 2 The cross-taper protects against both withdrawal symptoms and depressive relapse during the transition period.
Avoid combining bupropion with other medications that lower seizure threshold, including antipsychotics, theophylline, systemic corticosteroids, and stimulants. 1