Wellbutrin Dosing in Schizophrenia
Bupropion (Wellbutrin) should be initiated at 37.5 mg every morning, then increased by 37.5 mg every 3 days, with a maximum dose of 150 mg twice daily, and the second dose must be given before 3 p.m. to minimize insomnia risk. 1
Starting Dose and Titration Schedule
- Initial dose: 37.5 mg once daily in the morning 1
- Titration: Increase by 37.5 mg every 3 days as tolerated 1
- Target/Maximum dose: 150 mg twice daily 1
- Critical timing: Give the second dose before 3 p.m. to prevent insomnia 1
Essential Safety Requirements in Schizophrenia
Bupropion must only be used in patients with schizophrenia who are on stable antipsychotic medication. 2, 3 The evidence strongly demonstrates that:
- Without concurrent antipsychotics, 93% of bupropion-induced psychoses occurred 3
- With stable antipsychotic regimens, 229 schizophrenic patients were successfully treated without developing psychosis 3
- The risk of bupropion-induced psychosis is negligible when combined with antipsychotics 3
Contraindications Specific to Schizophrenia Patients
Do not use bupropion in:
- Agitated patients 1
- Patients with seizure disorders 1
- Patients not on stable antipsychotic medication 2, 3
Monitoring Requirements
EEG monitoring should be provided during treatment 2, as electroencephalographic abnormalities occur frequently even when psychotic symptoms remain stable 3
Clinical Indications in Schizophrenia
Bupropion may be considered for:
- Depressive symptoms in schizophrenia: Significant improvements in major depressive episodes have been documented 2
- Negative symptoms: Case series suggest potential benefit for anhedonia, amotivation, alogia, affective flattening, and passive social withdrawal 4, though one controlled trial showed no significant effect 5
- Smoking cessation: 36% abstinence rate at week 4 versus 7% with placebo 6
Treatment Duration and Response
- Assess response after 4-8 weeks of adequate dosing 1
- For smoking cessation, effects do not persist after discontinuation 6
- After 9 months, consider dosage reduction to reassess need 1
Important Clinical Pearls
The activating properties of bupropion can provide rapid improvement in energy levels 1, which may be beneficial for negative symptoms but problematic in agitated patients. The immediate-release formulation was associated with 57% of reported psychoses 3, so use extended-release formulations preferentially 2, 6.