Bupropion is the Better Choice for Your Situation
Given your presentation of fatigue, low motivation, mild motivational anhedonia, and subthreshold depressive symptoms (PHQ-9=6) in the context of ADHD and caregiver burnout, bupropion is a more appropriate first-line treatment than atomoxetine. Bupropion directly addresses your core complaints of fatigue and apathy through its dopaminergic effects, while also treating ADHD symptoms 1, 2.
Why Bupropion is Preferable in Your Case
Targets Your Specific Symptom Profile
Bupropion is particularly effective for symptoms of apathy and lack of energy in depression, with beneficial effects on dopamine levels 1. This directly addresses your fatigue and low motivation, which are your primary complaints.
Your presentation suggests caregiver burnout with depressive features (fatigue, anhedonia, low motivation) overlapping with ADHD symptoms. The American Academy of Family Physicians recommends bupropion as an activating antidepressant that improves energy levels and reduces apathy through its effects on dopamine and norepinephrine reuptake 1.
Bupropion is appropriate for anxiety when it occurs as part of a depressive syndrome, which fits your clinical picture with minimal anxiety (GAD-7=2) 1.
Evidence for ADHD Treatment
Low-quality evidence demonstrates that bupropion decreases the severity of ADHD symptoms (standardized mean difference -0.50) and increases the proportion of participants achieving clinical improvement (RR 1.50) 3.
A randomized, double-blind study showed bupropion (150 mg/day) was significantly more effective than placebo in treating adult ADHD after 6 weeks 2.
Guidelines note that bupropion has been shown to be more effective than placebo in adults with ADHD 4.
Why Atomoxetine is Less Ideal for You
Slower Onset and Different Symptom Profile
Atomoxetine requires 6-12 weeks until effects are observed, whereas you need more immediate relief from your fatigue and motivational symptoms 4.
Atomoxetine is a norepinephrine reuptake inhibitor without direct dopaminergic effects, making it less effective for apathy and energy deficits 4.
When comorbid mood symptoms are present, atomoxetine shows a slower rate of improvement than in pure ADHD 5.
Side Effect Profile
Atomoxetine commonly causes decreased appetite, headache, and stomach pain 4, which may be poorly tolerated when you're already dealing with caregiver stress.
The tolerability of bupropion is similar to placebo, with withdrawal rates due to adverse effects comparable to placebo 3.
Practical Implementation
Dosing Strategy
Start bupropion extended-release at 150 mg daily in the morning 1.
Take the medication before 3 PM to minimize insomnia risk 1.
Evaluate response after 12 weeks of treatment, though you may notice energy improvements earlier 1.
Monitoring Requirements
Monitor blood pressure, especially at treatment initiation 1.
Assess for improvement in both ADHD symptoms and depressive/fatigue symptoms.
Important Contraindications to Screen For
Avoid bupropion if you have a history of seizure disorders, eating disorders (anorexia or bulimia), or if you're abruptly discontinuing alcohol or benzodiazepines 1.
Ensure you're not taking MAOIs or haven't taken them within the past 14 days 1.
Clinical Caveat
The fact that your caregiver burden wasn't documented in your provider's notes is concerning, as this context is critical for treatment selection. Your fatigue and low motivation are likely multifactorial—stemming from both ADHD and chronic caregiver stress with emerging depressive features. Bupropion addresses both components more effectively than atomoxetine would 1, 2.