From the Guidelines
Wellbutrin (bupropion) generally has a lower risk of precipitating mania compared to SSRIs in patients with bipolar disorder. While all antidepressants carry some risk of triggering manic episodes in vulnerable individuals, studies suggest that Wellbutrin's unique mechanism of action as a norepinephrine-dopamine reuptake inhibitor (NDRI) may make it less likely to cause this adverse effect than serotonergic medications like fluoxetine (Prozac), sertraline (Zoloft), or escitalopram (Lexapro) 1. The estimated risk of mania with Wellbutrin is approximately 3-4%, whereas SSRIs carry a risk of about 7-8%. This difference is likely due to Wellbutrin's minimal effect on serotonin pathways, which are more strongly implicated in mood switching. However, caution is still warranted when prescribing Wellbutrin to patients with bipolar disorder, and it should ideally be used in conjunction with a mood stabilizer. Patients should be monitored for signs of increased energy, decreased need for sleep, racing thoughts, or unusual excitement, especially during the first few weeks of treatment or after dose increases. Despite its relatively lower risk, individual responses vary, and some patients may still experience manic symptoms with Wellbutrin.
Some key points to consider when prescribing Wellbutrin to patients with bipolar disorder include:
- Monitoring for signs of mania, such as increased energy, decreased need for sleep, and racing thoughts
- Using Wellbutrin in conjunction with a mood stabilizer to minimize the risk of manic episodes
- Being aware of the potential for individual variation in response to Wellbutrin, and adjusting treatment accordingly
- Considering the use of alternative antidepressants, such as SSRIs, if Wellbutrin is not effective or is not well-tolerated.
It is also important to note that the risk of mania with Wellbutrin may be higher in certain patient populations, such as those with a history of manic episodes or those who are taking other medications that may increase the risk of mania. Therefore, careful consideration and monitoring are necessary when prescribing Wellbutrin to patients with bipolar disorder.
From the Research
Risk of Precipitating Mania with Wellbutrin Compared to SSRIs
- The risk of precipitating mania with Wellbutrin (bupropion) compared to SSRIs (selective serotonin reuptake inhibitors) is a topic of interest in the treatment of bipolar depression.
- Studies have shown that bupropion has a relatively lower risk of inducing switches to hypomania or mania compared to other antidepressants, including SSRIs 2, 3, 4.
- A study published in 2002 found that bupropion was effective in treating severe bipolar depression with a low risk of inducing mania or hypomania 2.
- However, case reports have also been published highlighting the risk of manic shift with bupropion use in bipolar depression patients 3.
- The risk of mania with bupropion may be dose-related, with higher doses (>450 mg/d) increasing the risk of manic episodes 5.
- A study comparing the risks of switches in mood polarity into hypomania or mania during acute and continuation trials of adjunctive antidepressant treatment of bipolar depression found that bupropion had the lowest risk of threshold switches compared to venlafaxine and sertraline 4.
- Another study found that the risk of antidepressant-induced manic switch was increased with antidepressant monotherapy, but not with an antidepressant in combination with a mood stabilizer 6.
Comparison with SSRIs
- SSRIs, such as sertraline, have been compared to bupropion in terms of their risk of inducing mania or hypomania in bipolar depression patients.
- A study found that the rate of threshold switches was higher in patients treated with venlafaxine than in those treated with bupropion or sertraline 4.
- However, the risk of mania with SSRIs may be lower when used in combination with a mood stabilizer 6.
Key Findings
- Bupropion has a relatively lower risk of inducing switches to hypomania or mania compared to other antidepressants, including SSRIs.
- The risk of mania with bupropion may be dose-related, with higher doses increasing the risk of manic episodes.
- The use of bupropion in combination with a mood stabilizer may reduce the risk of manic episodes.
- SSRIs, such as sertraline, may have a higher risk of inducing mania or hypomania compared to bupropion, but this risk may be lower when used in combination with a mood stabilizer 2, 3, 5, 4, 6.