Emotional Lability on Wellbutrin: Clinical Significance and Management
Increased emotional reactivity or lability when starting bupropion is not a typical or expected side effect, and you should contact your doctor promptly to discuss this symptom. 1, 2
Understanding the Clinical Picture
Bupropion typically does NOT cause emotional blunting or increased emotional lability. In fact, research demonstrates that bupropion appears to cause less emotional blunting compared to SSRIs, with only 46% of patients on various antidepressants reporting emotional blunting, and this appeared less frequent with bupropion specifically. 3 Additionally, controlled trials showed that emotional responsiveness actually improved on average with bupropion, with only ≤6% of participants experiencing more emotional blunting post-treatment. 4
When to Contact Your Doctor Immediately
You should contact your doctor now if you are experiencing any of the following:
Unusual mood changes, agitation, irritability, or behavioral changes – particularly during the first 1–2 weeks of treatment, as bupropion carries an FDA black-box warning for increased suicidal thoughts in patients younger than 24 years. 1, 2
Signs of emerging mania or hypomania – including racing thoughts, decreased need for sleep, grandiosity, or impulsive behavior, as bupropion can unmask bipolar disorder and precipitate manic episodes. 2
Delusions, hallucinations, psychosis, concentration disturbance, paranoia, or confusion – these are serious neuropsychiatric adverse effects that require immediate discontinuation of bupropion. 2
Critical Differential Diagnosis
Your increased emotional lability could represent:
Undiagnosed bipolar disorder being unmasked – Bupropion can trigger manic or hypomanic episodes in patients with underlying bipolar disorder, and the National Comprehensive Cancer Network recommends avoiding treatment with SSRIs (and by extension, activating antidepressants like bupropion) in patients with bipolar depression due to risk of mania. 2
Neuropsychiatric toxicity from bupropion – The American College of Physicians and other guideline societies note that bupropion carries a black-box warning for development or worsening of serious neuropsychiatric issues, including depression, suicidal ideation/behavior, and mania, even in patients without previous psychiatric history. 2
Normal activation effects that may resolve – Early behavioral activation observed within the first month of therapy can sometimes be mistaken for worsening symptoms and often resolves with dose adjustment. 1
Recommended Action Plan
Do not wait for your symptoms to worsen or for the standard 6–8 week assessment period. 1 The FDA recommends immediate discontinuation of bupropion in patients who develop serious neuropsychiatric symptoms, and alternative treatments for depression should be considered, such as SSRIs. 2
Call your prescribing physician today to report:
- The specific nature of your emotional changes (crying more easily, mood swings, irritability, etc.)
- When the symptoms started relative to starting bupropion
- Any other new symptoms (sleep changes, energy changes, racing thoughts)
- Whether you have any personal or family history of bipolar disorder
Common Pitfalls to Avoid
Do not assume this will resolve on its own. While some activation effects can normalize, increased emotional lability is not a recognized common side effect of bupropion (the most common side effects are trouble sleeping, feeling anxious, stuffy nose, nausea, dry mouth, constipation, dizziness, and joint aches). 5
Do not stop bupropion abruptly without medical guidance. While your symptoms warrant urgent evaluation, medication changes should be supervised by your healthcare provider. 5
Do not dismiss these symptoms as "just adjusting to the medication." The highest risk period for serious neuropsychiatric adverse events is during the first 1–2 months of treatment, making early symptom reporting critical. 1, 2