Immediate Management: Discontinue Wellbutrin and Evaluate for Bipolar Disorder
Discontinue bupropion (Wellbutrin) immediately in this patient presenting with suicidal thoughts, increased energy, and agitation, as these symptoms represent serious neuropsychiatric adverse events that warrant drug cessation. 1
Immediate Actions Required
Stop bupropion now - The FDA drug label explicitly states that patients and caregivers should stop taking bupropion and contact a healthcare provider immediately if agitation, depressed mood, or changes in behavior that are not typical for the patient are observed, or if suicidal ideation develops 1. The combination of suicidal thoughts with increased energy and agitation is particularly concerning for either:
Critical Differential Diagnosis
Evaluate for Bipolar Disorder
This clinical presentation strongly suggests antidepressant-induced mood switch in a patient with undiagnosed bipolar disorder. The triad of suicidal thoughts, increased energy, and agitation after starting an antidepressant is classic for emerging hypomania/mania 1, 3.
Key point: Bupropion carries a black box warning that providers should monitor for development or worsening of serious neuropsychiatric issues including depression, suicidal ideation/behavior, and mania, even in patients without previous psychiatric history 5, 1. Although bupropion was historically considered to have lower risk of inducing mania compared to other antidepressants, multiple case reports demonstrate it can precipitate manic switches in bipolar patients 3, 4.
Specific Assessment Needed
- Psychiatric history: Screen for prior hypomanic/manic episodes, family history of bipolar disorder, history of antidepressant-induced activation 3
- Current symptoms: Assess for full manic/hypomanic criteria (decreased need for sleep, racing thoughts, pressured speech, grandiosity, impulsivity, risk-taking behavior) beyond just "increased energy" 1
- Suicidality assessment: Immediate evaluation of suicide risk with safety planning 1
Post-Discontinuation Management
If Bipolar Disorder is Confirmed
Do not restart any antidepressant monotherapy - Treatment with SSRIs should be avoided in patients with bipolar depression due to risk of mania 5. If this patient has bipolar disorder:
- Initiate mood stabilizer: Lithium, valproate, or carbamazepine as first-line treatment 3, 4
- Consider antipsychotic: If psychotic features or severe agitation present 4
- Monitor closely: Symptoms typically regress rapidly after bupropion discontinuation in drug-induced cases 4
If Unipolar Depression is Confirmed
If thorough evaluation rules out bipolar disorder and symptoms resolve after bupropion discontinuation:
- Switch to alternative antidepressant: Consider SSRI (sertraline, escitalopram) or SNRI as these have similar efficacy 5
- Close monitoring: The FDA mandates monitoring for emergence of agitation, irritability, unusual behavior changes, and suicidality, especially during initial treatment months 1
- Avoid bupropion rechallenge: Given this severe reaction 2
Ongoing Monitoring Requirements
Daily observation is required - Families and caregivers must monitor for emergence of agitation, irritability, unusual behavior changes, and suicidality, reporting symptoms immediately to healthcare providers 1. The FDA emphasizes this should include daily observation by families and caregivers 1.
Symptoms may persist after discontinuation - While many cases resolve after stopping bupropion, some symptoms persist and require ongoing monitoring and supportive care until resolution 1.
Critical Contraindications for Future Treatment
Never use bupropion again in this patient if bipolar disorder is diagnosed - Bupropion is contraindicated in bipolar disorder due to seizure risk with brain involvement and high risk of manic switching 5, 3, 4. Even when combined with mood stabilizers (lithium, carbamazepine, valproate), manic episodes can occur 3.
Document this adverse reaction prominently - This represents a serious drug reaction requiring permanent documentation in the medical record to prevent future exposure 2, 1.