Does Wellbutrin Help with Anxiety?
Wellbutrin (bupropion) is not recommended as a first-line treatment for anxiety disorders and may actually worsen anxiety symptoms in some patients, though it can effectively treat comorbid anxiety when it occurs alongside major depressive disorder. 1
Evidence for Anxiety Treatment
When Bupropion May Help Anxiety
In patients with major depressive disorder and comorbid anxiety, bupropion demonstrates comparable efficacy to SSRIs and SNRIs for reducing anxiety symptoms, showing no significant differences in anxiolytic effects 2, 1
The STAR*D trial found that comorbid anxiety does not affect bupropion's comparative efficacy when used as a switch or augmentation strategy for treatment-resistant depression 2, 3
Historical placebo-controlled trials showed bupropion significantly reduced anxiety symptoms in depressed inpatients compared to placebo on the Hamilton Anxiety Scale 4, 5
At 300 mg/day dosing, bupropion demonstrated some reduction in anxiety symptoms in hospitalized depressed patients, though the 450 mg/day dose did not show this benefit 5
When Bupropion May Worsen Anxiety
Bupropion's stimulating properties can provoke anxiety, particularly at higher doses, due to its norepinephrine and dopamine reuptake inhibition mechanism 1, 6
Common side effects include anxiety, insomnia, and agitation, which occurred in 0.6%-5.4% of patients in clinical trials 7, 8
The medication has activating properties that can increase agitation in susceptible patients, making it less suitable for those with primary anxiety disorders 3
Clinical Context and Recommendations
FDA Approval Status
- Bupropion is FDA-approved only for depression and smoking cessation, not for anxiety disorders 1
Comparison to Standard Anxiety Treatments
For primary anxiety disorders, SSRIs remain the first-line treatment rather than bupropion 7
When ADHD patients have comorbid anxiety that persists after stimulant treatment, clinicians should consider adding an SSRI rather than bupropion 7
Second-generation antidepressants showed no significant differences in treating accompanying anxiety symptoms in depressed patients, suggesting bupropion is not inferior but also not superior 9
Practical Prescribing Approach
If considering bupropion in a patient with depression and anxiety:
Start at lower doses (150 mg once daily for 3 days, then 150 mg twice daily) to minimize anxiogenic effects 3
Monitor closely for increased anxiety, agitation, or insomnia, especially in the first 1-2 weeks 3, 10
Administer the second dose before 3 PM to reduce insomnia risk, which can worsen anxiety 3
Assess response after 6-8 weeks before determining if the medication is effective 3
When Bupropion May Be Preferred Despite Anxiety
Bupropion offers specific advantages that may outweigh anxiety concerns in certain patients:
Significantly lower rates of sexual dysfunction compared to SSRIs 9, 3
Weight loss or weight neutrality rather than weight gain 9, 3
Beneficial for patients with comorbid depression and smoking cessation goals, addressing both conditions simultaneously 3, 10, 6
Useful for depressed patients with low energy, apathy, or hypersomnia due to its activating properties 3
Critical Safety Considerations
Maximum dose should not exceed 450 mg/day to maintain seizure risk at 0.1% 3
Contraindicated in patients with seizure disorders, eating disorders, or uncontrolled hypertension 8, 3
Monitor blood pressure and heart rate, especially in the first 12 weeks, as bupropion can elevate both 8, 3
Bottom Line
For pure anxiety disorders without depression, bupropion is not appropriate. For depression with comorbid mild-to-moderate anxiety, bupropion performs comparably to SSRIs but carries risk of worsening anxiety in some patients. SSRIs remain the safer first-line choice when anxiety is prominent, while bupropion should be reserved for cases where its unique benefits (no sexual dysfunction, weight neutrality, smoking cessation) align with patient needs and anxiety symptoms are not severe. 1, 9, 6