What is my role as a private practice provider in managing a college-aged patient with ADHD, prescribed Wellbutrin (bupropion) 300mg, who is experiencing a panic episode and odd behavior?

Your Role as a Private Practice Provider in This Acute Situation

Your immediate role is to ensure the patient's safety through direct communication with the patient and coordination with campus security, while documenting all actions taken and determining whether the current medication regimen requires urgent modification. 1

Immediate Actions Required

Direct Patient Contact

• Contact the patient immediately by phone or video to assess their current mental status and safety. You need to directly evaluate whether they are experiencing:
  • Acute psychosis or delirium (odd texts that don't make sense could indicate bupropion-induced psychotic symptoms) 1
  • Severe panic attack versus other psychiatric emergency
  • Medication-related adverse effects (bupropion can cause agitation, anxiety, and panic attacks, particularly at 300mg dosing) 1, 2

Safety Assessment

• Determine if the patient is currently safe with campus security or requires emergency department evaluation. Specifically assess for:
  • Suicidal or homicidal ideation (bupropion carries FDA warnings about increased suicidal thinking, particularly in young adults) 1
  • Psychotic symptoms including hallucinations, paranoia, or delusions 1
  • Severe agitation or behavioral dyscontrol that campus security cannot manage 1

Documentation Requirements

• Document all communications with the relative, patient, and campus security in real-time. This protects you medically and legally as the treating provider 3
• Record exact timing of when you were notified, actions taken, and clinical reasoning for decisions made

Clinical Decision Points

Medication Considerations

Bupropion at 300mg can cause neuropsychiatric adverse events including panic attacks, anxiety, agitation, and psychosis, particularly in young adults. 1, 2 You must determine:

• Whether the patient actually stopped using non-prescribed stimulants (combining stimulants with bupropion increases risk of seizures and psychiatric symptoms) 4
• If the "odd texts" represent bupropion-induced confusion, psychosis, or delirium versus primary psychiatric decompensation 1
• Whether this represents a panic episode (which bupropion can worsen due to its activating properties) versus more serious psychiatric emergency 5, 2

Immediate Medication Management

If the patient is experiencing bupropion-related adverse effects, instruct them to hold the medication immediately and do not restart until you can reassess. 1 Consider:

• Bupropion's activating properties can exacerbate anxiety and panic, particularly problematic if the patient has undiagnosed comorbid anxiety disorder 4, 2
• The 300mg dose may be too high if the patient is experiencing psychiatric adverse effects 1
• If stimulant use was not actually discontinued, the combination significantly increases risk of adverse neuropsychiatric events 4

Coordination of Care

Campus Resources

• Communicate directly with campus security to determine the patient's current status and whether they have transported the patient to emergency services. 3
• Provide campus security with specific symptoms to monitor: worsening confusion, agitation, suicidal statements, or inability to care for self

Emergency Department Involvement

If the patient exhibits psychotic symptoms, severe agitation, suicidal ideation, or cannot be adequately assessed via telepsych, direct campus security to transport to the nearest emergency department. 1 Provide the ED with:

• Current medication list (bupropion 300mg)
• History of non-prescribed stimulant use
• Your contact information for consultation

Family Communication

• Contact the relative back to provide an update on your assessment and plan. 3
• Clarify what specific symptoms they observed in the texts
• Determine if they have additional information about possible continued stimulant use or other substance use

Common Pitfalls to Avoid

• Do not assume this is simply a panic attack without ruling out bupropion-induced psychosis or delirium, which requires immediate medication discontinuation. 1
• Do not continue bupropion if the patient is still using non-prescribed stimulants—this combination significantly increases seizure risk and psychiatric adverse effects. 4, 1
• Do not rely solely on the relative's report without direct patient assessment—you need to evaluate mental status yourself. 3
• Do not delay documentation—document all communications and clinical decisions in real-time to protect yourself legally. 3

Follow-Up Planning

If Patient is Stable

• Schedule urgent follow-up within 24-48 hours to reassess symptoms and medication regimen. 6
• Consider whether bupropion is appropriate given possible panic symptoms (bupropion's activating properties can worsen anxiety and panic) 4, 2
• Verify stimulant abstinence through urine drug screening at next visit 4

If Medication Change Needed

If bupropion is discontinued due to adverse effects, consider alternative ADHD treatments: 6, 4

• Long-acting stimulants (if stimulant abstinence can be verified and monitored closely) 6, 4
• Atomoxetine (non-stimulant with lower abuse potential, though requires monitoring for suicidality) 6, 4
• Alpha-2 agonists like guanfacine if anxiety or agitation is prominent 6, 4