Bupropion Can Help Depression But Will Likely Worsen Anxiety and Procrastination
Bupropion is FDA-approved and effective for major depressive disorder, but it is an "activating" antidepressant that commonly increases anxiety in susceptible patients and should be avoided when anxiety symptoms are prominent. 1, 2, 3
Why Bupropion Works for Depression
- Bupropion demonstrated significant superiority over placebo in multiple controlled trials for major depressive disorder, with response rates of 60-70% compared to 30% for placebo 3, 4
- The FDA label confirms efficacy was established in two 4-week inpatient trials and one 6-week outpatient trial, with maintenance efficacy demonstrated up to 44 weeks 3
- Bupropion at 300 mg daily has been shown effective for long-term treatment of recurrent major depression 5
Why Bupropion Will Not Help—and May Worsen—Anxiety and Procrastination
The American Academy of Family Physicians explicitly notes that bupropion is an "activating" antidepressant that can increase anxiety in susceptible patients, particularly those with a history of anxiety disorders. 1
- The FDA label warns that bupropion should not be used in agitated patients, and increased anxiety represents treatment-emergent agitation 2
- Common adverse effects include anxiety, insomnia, and agitation—all of which would exacerbate procrastination symptoms 3, 6
- The American Academy of Child and Adolescent Psychiatry advises against using bupropion monotherapy for generalized anxiety disorder, as it lacks efficacy for anxiety and may worsen symptoms 7
What Actually Works for Comorbid Depression and Anxiety
Sertraline is specifically recommended as the first-line SSRI for patients with both depression and anxiety due to its optimal balance of efficacy, safety, and tolerability. 2
- The American College of Physicians guideline shows that second-generation antidepressants (SSRIs) demonstrated similar antidepressive efficacy for patients with major depressive disorder and anxiety symptoms 5
- Sertraline is FDA-approved for major depressive disorder, panic disorder, social anxiety disorder, generalized anxiety disorder, and PTSD 2
- Evidence from 6 fair-quality head-to-head trials showed similar efficacy between sertraline and bupropion for depression with anxiety, but sertraline does not carry the activating properties that worsen anxiety 5
Practical Implementation
- Start sertraline 50 mg daily in the morning 2
- Increase in 50 mg increments at 1-2 week intervals if response is inadequate, up to a maximum of 200 mg daily 2
- Allow 6-8 weeks for an adequate trial, including at least 2 weeks at the maximum tolerated dose 2
- Monitor for treatment-emergent suicidality closely during the first 1-2 weeks after initiation or dose changes 2
Critical Pitfall to Avoid
Do not continue bupropion hoping the anxiety will resolve—the activating properties are intrinsic to the medication and unlikely to improve with time in an already anxious patient. 2
- Bupropion's mechanism as a dopamine and norepinephrine reuptake inhibitor inherently causes activation 5
- The absence of sedative effects, while beneficial for some patients, contributes to increased anxiety and agitation in anxiety-prone individuals 8, 9
If First-Line SSRI Fails
- Switch to venlafaxine extended-release 75-225 mg daily, which demonstrated statistically significantly better response rates than fluoxetine specifically for depression with prominent anxiety symptoms 5, 2
- Consider adding cognitive behavioral therapy, as combination treatment (CBT + SSRI) is superior to either alone for anxiety disorders 2