Bupropion Addition for SSRI-Induced Somnolence
Add bupropion to this patient's sertraline regimen to address the increased somnolence and hypersomnia. 1
Rationale for Bupropion
Bupropion is the optimal choice in this clinical scenario for several compelling reasons:
- Activating properties: Bupropion is specifically noted to be "activating" with potential for rapid improvement of energy level, making it ideal for counteracting SSRI-induced somnolence 1
- Complementary mechanism: As a dopamine-norepinephrine reuptake inhibitor with no serotonergic activity, bupropion provides mechanistic augmentation to sertraline's selective serotonin effects 2, 3
- Favorable side effect profile: Bupropion has significantly lower rates of sexual dysfunction compared to SSRIs and does not cause the somnolence or weight gain seen with other antidepressants 1
- Proven efficacy: Bupropion demonstrates equivalent antidepressant efficacy to SSRIs while specifically addressing fatigue and energy deficits 2
Why Not the Other Options
Desipramine is a tricyclic antidepressant that, while activating, carries significant risks of cardiotoxicity, hypotension, anticholinergic effects, and tachycardia—unnecessary risks in a young, otherwise healthy patient 1
Fluoxetine is another SSRI that would not address the somnolence problem and could potentially worsen it, as SSRIs commonly cause somnolence as a class effect 1
Olanzapine is an antipsychotic with potent sedating properties that would dramatically worsen the patient's hypersomnia; it's indicated only when psychotic features are present, which this patient lacks 1
Phenelzine is a monoamine oxidase inhibitor with significant cardiovascular side effects including hypertension and hypotension, plus dangerous dietary restrictions—completely inappropriate as augmentation therapy in this straightforward case 1
Dosing and Administration
- Initial dose: Start bupropion at 37.5 mg every morning, then increase by 37.5 mg every 3 days 1
- Target dose: 150 mg twice daily (maximum dose) 1
- Timing consideration: Give the second dose before 3 p.m. to minimize risk of insomnia 1
- Contraindications: Do not use in patients with seizure disorders or in agitated patients 1
Monitoring and Follow-up
- Reassess within 1-2 weeks of initiating bupropion to evaluate response and monitor for adverse effects 1
- Evaluate therapeutic response at 6-8 weeks: If inadequate response, consider further treatment modifications 1
- Monitor for seizure risk: While bupropion carries a slightly increased seizure risk, this is dose-dependent and minimized by gradual titration and staying within recommended dosing limits 1
- Watch for activation: Some patients may experience initial nervousness or insomnia, which typically resolves; timing the second dose appropriately helps prevent this 1
Expected Outcomes
Patients typically experience improvement in energy levels and reduction in somnolence within 2 weeks, with full antidepressant efficacy achieved by 4 weeks of combined therapy 2, 3