Immediate Medication Review and Discontinuation of Bupropion
Discontinue Wellbutrin (bupropion) immediately, as the FDA explicitly warns that bupropion can cause hallucinations, psychosis, paranoia, and delusions, particularly in patients without prior psychotic history. 1
Critical First Step: Rule Out Medication-Induced Psychosis
The FDA drug label for bupropion specifically states that patients have experienced "psychosis, hallucinations, paranoia, delusions" and instructs patients to "discontinue bupropion" if they experience such symptoms. 1 This is your most likely culprit given:
- Bupropion's known psychiatric adverse effects: The medication can cause agitation, hallucinations, and psychosis even in patients without prior psychiatric history 1, 2
- Patient age and presentation: A 30-year-old with new-onset auditory AND visual hallucinations on bupropion fits the classic medication-induced psychosis profile 3
Secondary Consideration: Evaluate Other Medications
While less likely, both trazodone and oxcarbazepine warrant evaluation:
- Trazodone: Can cause hallucinations in dementia patients, but this is primarily documented in elderly populations with cognitive impairment, not young adults 4, 5
- Oxcarbazepine: Generally well-tolerated for seizure control with minimal psychiatric side effects at 300mg BID 4
Immediate Management Algorithm
Step 1: Stop Bupropion Immediately
- The FDA mandates discontinuation when hallucinations occur 1
- Do not taper—immediate cessation is recommended for psychiatric adverse effects 1
Step 2: Initiate Antipsychotic Treatment
Start quetiapine 25mg orally for acute symptom control, as it provides effective management of hallucinations with lower risk of extrapyramidal symptoms compared to typical antipsychotics. 6
- Dosing: 25mg orally as initial dose, can repeat every 12 hours if needed 6
- Advantages: Sedating properties help with distress, minimal EPS risk, no prolactin elevation 6
- Monitoring: Check blood pressure for orthostatic hypotension after first dose 6
Step 3: Rule Out Non-Psychiatric Causes
Before assuming primary psychotic disorder, evaluate for:
- Hearing impairment: Auditory hallucinations can result from acquired hearing loss through deafferentation phenomenon 7
- Vision impairment: Visual hallucinations may indicate Charles Bonnet syndrome if any degree of vision loss exists 4
- Recent head trauma or seizure activity: Given oxcarbazepine use, confirm seizure history 8
- Other medications or substances: Review for any recent additions or changes 3
Expected Timeline and Monitoring
- Symptom resolution: If bupropion-induced, hallucinations should improve within 24-72 hours of discontinuation 1
- Quetiapine response: Expect reduction in hallucination frequency and distress within first dose 6
- If symptoms persist beyond 5-7 days: Consider alternative diagnoses including primary psychotic disorder, and refer for psychiatric evaluation 3
Critical Pitfalls to Avoid
Do not assume primary psychotic disorder without ruling out medication causes first. When patients with no psychotic history present with hallucinations, particularly both visual and auditory, medication-induced psychosis is more likely than schizophrenia. 3
Do not continue bupropion "to see if symptoms resolve"—the FDA explicitly requires discontinuation when hallucinations occur. 1
Do not use trazodone for acute hallucination management—it has delayed onset and is inappropriate for acute psychotic symptoms. 5
Alternative Antipsychotic Options If Quetiapine Not Tolerated
- Olanzapine 2.5mg daily: Well-tolerated with good efficacy for hallucinations 4
- Risperidone 0.25mg daily: Effective but higher EPS risk than quetiapine 4, 7
- Aripiprazole: Lower sedation but effective for psychotic symptoms 4
Addressing the Underlying Depression
Once hallucinations resolve: