Can a 59-year-old patient with a history of anxiety, increasing depression, and an eating disorder, who recently quit smoking 6 months ago, be treated with bupropion (Wellbutrin) for their depression and anxiety?

Bupropion is Absolutely Contraindicated in This Patient Due to the Eating Disorder

Bupropion should NOT be prescribed to this patient because the presence of an eating disorder (bulimia nervosa or anorexia nervosa) is an absolute contraindication to bupropion use, regardless of the potential benefits for depression or smoking cessation. 1, 2

Critical Contraindication: Eating Disorders

• The American Psychiatric Association explicitly contraindicates bupropion in patients with current or prior bulimia or anorexia nervosa due to significantly higher seizure incidence observed in these populations. 2
• The seizure risk in eating disorder patients taking bupropion is substantially elevated beyond the baseline 0.1% (1 in 1,000) risk seen in general populations at therapeutic doses. 1
• This contraindication applies to all bupropion formulations (IR, SR, XL) and all indications (depression, smoking cessation, weight management). 1, 2

Evidence Supporting This Contraindication

• Case reports document severe abuse of bupropion XR reaching 3,000-4,500 mg/day in a patient with bulimia nervosa, resulting in grand mal seizures, tachycardia, and severe anxiety. 3
• The stimulant, euphoriant, and anorexic effects of bupropion contribute to its abuse potential specifically among eating disorder patients. 3
• Even at therapeutic doses, the combination of eating disorder pathophysiology and bupropion's seizure threshold-lowering effects creates unacceptable risk. 1, 2

Additional Contraindication Screening Required

Before considering any alternative antidepressant, verify the patient does not have:

• Seizure disorder or epilepsy history 2
• Uncontrolled hypertension (bupropion elevates blood pressure) 4, 2
• Current MAOI use or use within 14 days 1
• Abrupt discontinuation of alcohol, benzodiazepines, or antiepileptic drugs 1

Alternative Treatment Approach

For this 59-year-old patient with anxiety, increasing depression, recent smoking cessation, and an eating disorder, consider:

First-Line Alternatives

• SSRIs (sertraline, escitalopram, fluoxetine) are appropriate first-line agents for depression with comorbid anxiety and have established safety profiles in eating disorder populations. 5
• Sertraline 200 mg/day has demonstrated efficacy in depressed patients with binge eating disorder, though with less weight loss benefit than bupropion. 6
• SSRIs address both depression and anxiety symptoms, which is particularly relevant given this patient's dual presentation. 5

Addressing Post-Smoking Cessation Depression

• Depression and anxiety commonly increase after smoking cessation due to nicotine withdrawal effects that typically peak within 1-2 weeks and gradually subside. 1
• At 6 months post-cessation, persistent mood symptoms likely represent independent major depressive disorder rather than withdrawal alone. 1
• The patient requires antidepressant treatment, but bupropion's dual benefit for smoking cessation is irrelevant since cessation already occurred 6 months ago. 1

Critical Clinical Pitfall to Avoid

• Do not rationalize bupropion use by focusing on its benefits for depression or past smoking history while minimizing the eating disorder contraindication. The seizure risk is absolute and potentially life-threatening. 2, 3
• Clinicians must screen for eating disorder history before prescribing bupropion, as this contraindication is frequently overlooked in clinical practice. 3

Monitoring Requirements for Alternative Antidepressants

• Assess response within 1-2 weeks of initiation for adverse effects and early therapeutic response. 2
• Allow 6-8 weeks at adequate dose before determining treatment response. 1, 2
• Monitor closely for suicidal ideation, especially in the first 1-2 months of treatment. 1

Why Bupropion Cannot Be Used Despite Potential Benefits

While bupropion offers theoretical advantages for this patient (activating properties for depression, history of smoking cessation, potential weight management), the eating disorder contraindication supersedes all potential benefits. 2 The risk of seizures, medication abuse, and adverse outcomes in eating disorder populations makes bupropion use medically and ethically unjustifiable. 3