Bipolar Beat

With this post, we continue our sort-of-biweekly series on medications used to treat bipolar disorder and related symptoms. A few weeks ago, we wrapped up our coverage of SSNRI antidepressants with Cymbalta (Duloxetine). This week, we turn our attention to an antidepressant that’s in a class of its own – Wellbutrin (bupropion), also marketed as Zyban for smoking cessation.

Wellbutrin appears to work by increasing the levels of dopamine and norepinephrine in the brain synapses. It has a completely different mechanism of action from antidepressants in other classes, such as SSRIs, SSNRIs, and tricyclics; therefore, it belongs in its own category. Other uses include treating nicotine addiction (as with Zyban) and possibly treating ADHD. Wellbutrin does not have any primary anti-anxiety effects, but for people experiencing anxiety in the context of a major depressive episode it may relieve that type of anxiety.

Potential Benefits

Wellbutrin is an antidepressant that is FDA approved for the treatment of Major Depressive Disorder (MDD) and Seasonal Affective Disorder (SAD). The product Zyban, which is the same chemical product (bupropion), is marketed as approved for smoking cessation. Wellbutrin offers some additional benefits:

  • Reduces nicotine cravings; even for people not trying to quit smoking, it may reduce their nicotine use.
  • It does not produce negative effects on sexual function and in some cases may enhance sexual function.
  • It is generally weight neutral – it does not cause weight gain and can sometimes assist with weight loss.
  • It does not cause fatigue; it more typically increases energy and alertness.
  • It is thought to be less likely to trigger a manic episode than other antidepressants, although the jury is still out on this.

Potential Side Effects

Wellbutrin is generally well tolerated and (as explained above) avoids some of the more problematic side effects of other classes of antidepressants – especially sexual side effects and weight gain. However, it does carry the possibility of causing the following side effects:

  • Jitteriness, insomnia, anxiety – Wellbutrin is a distant relative of stimulant medications. so it can cause stimulating side effects. These are probably the most common reasons someone would stop this medication.
  • Decreased appetite and weight loss, which is more often a benefit but can be a drawback for some people.
  • Tinnitus – ringing in the ears.
  • Strong interactions with a number of medications, most notably tamoxifen, that are metabolized by certain liver enzymes.
  • Seizures – this is the most dangerous side effect of Wellbutrin and while rare does occur. The risk is between 0.1 and 0.4% of people taking Wellbutrin, and the risk is reduced by staying below recommended ceiling dosages and using extended release formulations. The risk is increased for people with other predisposing factors to seizures, including head injuries, previously undetected seizures or seizure disorder, or combination with other medications that either lower the seizure threshold or increase blood levels of Wellbutrin.
  • Wellbutrin is contraindicated for people with eating disorders. The risk of seizure side effect is increased in this population.
  • Alcohol can change the seizure threshold, so drinking should be limited while taking Bupropion.

Typical Dose

Wellbutrin is available in several different forms, each of which has its own dosing recommendation:

  • Wellbutrin IR (Immediate Release): 75 to 150 mg taken twice or three times daily for a total dose of 300 to 450 mg per day.
  • Wellbutrin SR (Sustained Release): 100 to 200 mg taken twice daily (typically morning and afternoon) for a total dose of 200 to 400 mg per day.
  • Wellbutrin XL (Extended Release): 150 mg to 450 mg taken once daily (typically in the morning).

These are typical doses. Follow your doctor’s recommendation to determine which form is best for you, how much to take, and when to take it.

Remember: Any antidepressant can take 2-3 weeks or even longer to become fully effective, and it may take several weeks to work up to a therapeutic dose, so your depression may not lift for several weeks. Patience is key. Give the medication a few weeks to become effective and give your body a few weeks to adjust to it. Any negative side effects you experience are likely to fade over time.

Schedule an appointment to follow up with your doctor 3-4 weeks after you start taking the medication, but don’t hesitate to call earlier if you’re concerned about the medication’s effectiveness or any side effects you may be experiencing.

Wellbutrin in My Practice

I use Wellbutrin frequently in my practice. For individuals with depression without a primary anxiety disorder, it is typically a first choice unless contraindicated due to any other existing conditions. It is well tolerated in general and the lack of sexual side effects and weight gain is a big plus for many people. It also may offer some support to symptoms of inattention and distractibility – so if there is some overlapping ADHD, I will consider Wellbutrin sooner rather than later. The general feeling that it causes less manic switching – treatment emergent hypomania or mania – has been borne out in my use of Wellbutrin – I have not found this to be a significant problem.

Another niche for Wellbutrin is to add it to an SSRI. I might do this if the SSRI has been effective but not fully effective, because Wellbutrin operates completely differently from the SSRI and may add to the antidepressant effect or because of sexual side effects from the SSRI. Wellbutrin is helpful in reducing the sexual side effects from SSRI’s for many people – I have found it very useful in this way.

I have had only a couple of patients develop seizures on this medication, and at least one of them was suffering with eating disorder symptoms that she was keeping secret from everyone. So she did have a predisposing factor. It is critical to be honest with your prescriber about all of your symptoms and medicine and substance use, because they can be very important when the doctor chooses medications to use in your situation.

More Information and Call for Comments

For more information from the manufacturer, visit GlaxoSmithKline’s Wellbutrin SR page.

If you’ve taken any form of Wellbutrin for bipolar depression or other conditions or are a doctor who has prescribed it, please share your experiences, insights, and observations.


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Links to This Article

From Psych Central's Dr. Candida Fink & Joe Kraynak:
Bipolar Disorder Medication Spotlight: Tricyclics | Bipolar Beat (August 7, 2009)

11 Comments to
“Bipolar Disorder Medication Spotlight: Wellbutrin (Bupropion)”

I took Wellbutrin SR after unsuccessful trials of paxil CR, Effexor XR (effective, but caused a substantial weight loss that was too unhealthy), and zoloft. I had a diagnosis of major depression, severe, recurrent, and no history of anxiety, panic attacks, or ADD/ADHD. 12 years later, that diagnosis has shifted a bit to bipolar II, but still no history of anxiety, panic attacks, or ADD/ADHD.

Within two days, I was laying curled up on my bedroom floor, shaking, and crying. I could not stop crying, and I began experiencing panic attacks – which I had never experienced before or since. My doctor wanted to stick it out a little longer and see if those effects would fade, but after two weeks of nearly nonstop crying and frequent (multiple and daily) panic attacks, he too agreed it was drug related and pulled me off.

This was 12 years ago and I haven’t had a panic attack since. Wellbutrin was hell for me. I don’t care how much time has passed and how realistic it is that my brain may now process it’s chemicals differently – I won’t go near it.

Bear in mind.

I have tried nearly every SSRI on the market with the exception of Prozack and the newer drugs like Cymbalta. My orginal diagnosis was Major Depressive Disorder with Panic Attacks. Having mild depressive symptoms most of my life these magnified after 15 years of an unhappy marriage, three children and a very stressful job where I was responsible for the lives of 100 children daily in the form of transportation. After several years of therapy a new diagnosis made complex PTSD with bipolar 1. WELLBRUTRIN HAS PROVEN IN MY CASE TO BE THE BEST drug to manage my symptoms. I will say that it sems after 18 months or so the positive effects of the medication fade. Others I have spoken to have experienced this. With that in mind and due to added stress of our son getting married last fall I asked to include a low dose of PAXIL 10mg daily. Six months and Twentyfive lbs later(all around my middle) I quit cold turkey. I had quit the Wellbrutrin cold turkey n the past and had mild arm and head zaps. Quiting with the paxil was sheer HELL. I liken it to with drawl from any street drug. It took three weeks to feel better. That was Feb 1 2009. I have not ben on any meds since. I am just starting to feel my depression coming on again. I am going to try the fall and winter months on with the spring and fall months off this year. Everyone is in individual find the right med for you. BTW ~ Abilify caused me to have feelings of murder WITH NO REMORSE. Thank God I had the brains to stop it ASAP! If you have close relatives on a med that works for them try it.

Good luck ~ find a good therapist to.

For over 17 years, I have taken Wellbutrin or the generic equivalent in combination with Zoloft or Celexa. The SSRIs had no impact on my symptoms (Bipolar/MMD/PTSD/anxiety disorder) until the Wellbutrin was introduced.

In terms of side-effects, Wellbutrin does curb my appetite and is the apparent cause of dermatitis on my scalp and nape of the neck.

My question is this: Shortly before falling asleep, I twitch involuntarily. The twitches seem to originate at the base of my spine. My husband tells me it they can be quite powerful. As I age, they seem to be getting more intense. I have a hunch they are due to the meds. Anyone else out there have this experience? Should I be worried?

Dear Olivia,
These twitches you have when first relaxing to go to sleep are likely part of the relaxation process, common in many people. If you are ever extra physically exhausted and have been doing heavy physical work or are otherwise stressed, dehydrated, low on minerals or even post menopausal it might be weird for you to have never had this experience! I have occasionally had this experience for one or several of these reasons and have seen it in my husband, kids (both when they were young and young adults), and my elderly mother. I don’t think they are related to wellbutrin, I take it, too. Great stuff!

I have been on 150 mg of bupropion HCL XL since June 15, 2009. My doctor put me on it after I explained that Celexa was no longer effective. I tapered off the Celexa for two weeks while starting on bupropion. I had a good two to three weeks in which I was highly motivated and upbeat. Then my mood changed. I’m crying every day, not as motivated, and last week I had two panic attacks on the way to an exam. I was driving at the time, so it was extremely terrifying. I have a check-up with my doctor in a few days, so I’ll tell him about my panic attacks. But I’m still puzzled as to how I could go from having so much energy to back to my old, unmotivated self in just a few weeks. Has this happened to anyone?

I was prescribed Wellbutrin following a major depressive episode and it worked wonderfully for me–I had no recurrence of depression, it evened out my sleep schedule, and I was able to handle things better. I forgot to get a refill and because of some delays with my doctor’s office (I moved to another city and transferring records was a problem), I ended up going a month or two without it and went into something resembling mania.

The doctor in my new city took me off of Wellbutrin and put me on lithium instead for Bipolar I–something I resist taking because of numerous reasons, not least of which the Wellbutrin obviously worked.

In short, it worked well for me, save for a few dizziness spells now and again.

Dear All-
first of all I just want to say Thank You to medical science for providing help where there was limited choices years ago. I started with panic attacks and depression as child and went undiagnosed until my mid thirties when I was take to the hospital for severe chest pains, which turned out to be part of the panic disorder. I was Prescribed Prozac and I took it for many years as it did relieve me of all panic symptoms EXCEPT I experienced a major loss of libido which truly affected my marriage. Years later I had several major losses- loss of my mom, loss of my job and 3 back surgeries which left me disabled and I was thrown into full blown depression. I was taken off the Prozac and put on Cymbalta which I did NOT tolerte. In fact, it made me completely manic and went through literal HELL in the weaning off process. I started going to talk thrapy and was prescribed Wellbutrin which has been a Godsend. My conclusion is that any kind of medications for mental health issues are a literal crap shoot as everyone reacts differently, whether it is an anti depressant, anti anxiety or treatment for ADHD, ADD, Bi-Polar or Obsessive Compulsive disorders. The sad thibg is that somewhere, there is the right medicine for you. It is just finding it, that is scary. Now my 24 yr old daughter is experiencing similar traits(started with panic attacks and has since moved past that to what appears to be Bi-Polar mania)and she is scared to take any meds and I cannot blamne her as she too has had bad efects from Paxil and Effexor- She tolerated the Prozac as I did but no longer needs to take it due to the change in her symptoms and she too has expressed sexual problems due to reduced libido from the seratonin in Prozac. I am praying that since I tolerated the Wellbutrin and can also be used to treat Bi-Polar issues, that she will ot have to go through the “gineau pig” stage and start feeling better right away. I pray that whoever reads this does not give up hope.

I am a 53 year old woman who has tried many of the anti-depressants menioned here for my depression. Prozac gave me migranes, zoloft made me sleep all the time, I too thought that Wellbutrin was the answer because when I first started taking it I felt well for a year but noticed tremors in my head and right hand. I went to a specialist and was tested with those little electrical shocks and told that I had genetic tremors! That I had inherited this! Even tho’ I had told this Dr. all the meds I was on he missed the diagnosis. I quit taking the Wellbutrin and the tremors went away…I agree with the woman who said you have to not give up and try many different medicines until you find the one that works for you. I have’nt given up hope.

I wonder if Wellbutrin will help me, a 53 year old postmenopausal woman with a lack of desire for sex to increase my sex drive. My sex drive disappeared all of a sudden two years ago, and I haven’t had a period for a year and a half. If it does help, what is the dosage? I had a lumpectomy for breast cancer 13 years ago, so I can not take hormones. HELP

Could you please tell me why Bupropion causes seizures for people with eating disorders history? I have this disorder (compulsive eating) but my doctor thinks I should try this drug anyway (since it reduces appetite) I am very willing to try it too, but I was just wondering how serious are those seizures and what should I do i that happens. ?
Thanks.

I “sampled” Wellbutrin for several days after it being suggested by my doctor that it may be an option. I took 150mg & in an hour or so afterwards I felt like I had drank three cups of coffee. I started to clean my kitchen & organise things, etc. Generally improved my mood & energy (I cleaned & reorganised my room during the days I was taking it) after the sample ran out I slammed back down to a depression that lasted a few days, first fast & hard one night two days after having run out.

So yeah I had withdrawals, not the best med for me. I was later discovered to be bipolar instead of cliniclayy depressed. I find it very odd that some suggest that Wellbutrin has a lower risk of trigger mania than other antidepressants. Being a distant relative of a stimulant, I would think it would have the most pontential to spin out a manic episode. However, I am not an expert on the brain so therefore I can’t say.

I still scratch my head on whether or not my sudden & intense reaction to Wellbutrin (I am quite sensitive & tend to react sooner to meds than normal) was a sign of bipolar. Who knows.

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    Last reviewed: 21 Jul 2009

 


Candida Fink, M.D. and Joe Kraynak are authors of Bipolar Disorder for Dummies. Pick up the book today!


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