Those studies were done in patients with anxious depression, but what about patients with a separate anxiety disorder. Here bupropion may not fare as well, unless that anxiety disorder is the generalized type (GAD). In GAD, bupropion performed just as well as escitalopram (Lexapro) in a small head-to-head controlled trial.6 However, bupropion has failed in very small trials of panic disorder, post traumatic stress disorder (PTSD), and obsessive-compulsive disorder (OCD).
Another Myth (#4): Bupropion isn’t a good fit for patients with insomnia
This one is partly true. Bupropion (along with desvenlafaxine) does carry a higher risk of causing initiation insomnia than the other antidepressants, but the difference is very small. Most second-generation antidepressants can cause insomnia, and the rates are similar.7 However, sleep quality is a different matter, and here bupropion shines. Depression impairs sleep architecture in several ways. There is more REM latency (the patient enters REM too quickly), REM density, and less of the restorative slow-wave sleep. Bupropion reverses those changes, while the SSRIs tend to make them worse.
It’s a paradox that the SSRIs can treat depression while worsening sleep quality.[8 ]They can also cause restless leg syndrome, something that bupropion can treat, according to a recent randomized controlled trial.[9,10]
On the other hand, bupropion does stand out among the antidepressants as having a positive effect on energy.11 When patients are up and active during the day, they are likely to sleep better at night. To me, activity level is a much more important outcome in depression than the amount of time it takes to fall asleep, so I won’t shy from choosing bupropion in a patient with insomnia.
Dr Aiken is Instructor in Clinical Psychiatry at the Wake Forest University School of Medicine and the Director of the Mood Treatment Center in Winston-Salem, NC. He is Editor in Chief of The Carlat Psychiatry Report and Section Editor for Psychiatric Times.
Dr Aiken does not accept honoraria from pharmaceutical companies but receives royalties from W.W. Norton & Co. for a book he co-authored with James Phelps, MD, Bipolar, Not So Much.
1. Steinert T, Fröscher W. Epileptic Seizures Under Antidepressive Drug Treatment: Systematic Review. Pharmacopsychiatry, 2018;51(4):121-135.
2. Finkelstein Y, Macdonald EM, Li P, et al. Second-generation anti-depressants and risk of new-onset seizures in the elderly. Clin Toxicol (Phila), 2018;56(12):1179-1184.
3. Zimmerman M, Posternak MA, Attiullah N, et al. Why isn't bupropion the most frequently prescribed antidepressant? J Clin Psychiatry 2005;66(5):603-610.
4. Papakostas GI, Trivedi MH, Alpert JE, et al. Efficacy of bupropion and the selective serotonin reuptake inhibitors in the treatment of anxiety symptoms in major depressive disorder: a meta-analysis of individual patient data from 10 double-blind, randomized clinical trials. J Psychiatr Res, 2008;42(2):134-140.
5. Papakostas GI, Stahl SM, Krishen A, et al. Efficacy of bupropion and the selective serotonin reuptake inhibitors in the treatment of major depressive disorder with high levels of anxiety (anxious depression): a pooled analysis of 10 studies. J Clin Psychiatry, 2008;69(8):1287-1292.
6. Bystritsky A, Kerwin L, Feusner JD, et al. A pilot controlled trial of bupropion XL versus escitalopram in generalized anxiety disorder. Psychopharmacol Bull, 2008;41:46-51.
7. Ott GE, Rao U, Lin KM, et al. Effect of treatment with bupropion on EEG sleep: relationship to antidepressant response. Int J Neuropsychopharmacol. 2004;7:275-281.
8. Mayers AG, Baldwin DS. Antidepressants and their effect on sleep. Hum Psychopharmacol. 2005;20:533-559.
9. Rottach KG, Schaner BM, Kirch MH, et al. Restless legs syndrome as side effect of second generation antidepressants. J Psychiatr Res. 2008;43:70-75.
10. Bayard M, Bailey B, Acharya D, et al. Bupropion and restless legs syndrome: a randomized controlled trial. J Am Board Fam Med. 2011;24:422-428.
11. Alberti S, Chiesa A, Andrisano C, et al. Insomnia and somnolence associated with second-generation antidepressants during the treatment of major depression: a meta-analysis. J Clin Psychopharmacol, 2015;35(3):296-303.