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.
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.
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.