Y/N, yes/no; I, instant-release formulation; S, sustained release; W, week; D, day; H, hour.

Acute psychosis after bupropion treatment in a healthy 28-year-old woman

Design

Case presentation

A 28-year-old female presented with a primary concern of tobacco dependence and expressed a strong desire to cease smoking. Her medical history included a single episode of anxiety, which resolved without medical intervention, and infrequent gastrointestinal spasms managed with hyoscyamine. She had no significant surgical history, and her family history was devoid of psychiatric conditions. Her social history revealed a three-pack-per-year smoking habit, minimal alcohol consumption, and no use of illicit drugs. In response to her desire to quit smoking, the patient was initiated on bupropion (Wellbutrin SR) 100 mg daily, with a planned titration to 150 mg twice daily by the end of the second week. The potential risks and benefits of the treatment were thoroughly discussed, and the patient was advised to report any concerns.

One week after starting treatment, the patient contacted the clinic reporting severe paranoia, fearing that someone intended to harm her and her children. She also experienced panic attacks, suicidal ideation, and auditory hallucinations instructing her to self-harm. Despite these severe psychiatric symptoms, her orientation and memory remained intact. The patient declined in-person evaluation and dismissed the ideation as "silly" and "unreal," insisting she would not act on these thoughts. Following the discontinuation of bupropion, all psychiatric symptoms resolved within one week. At a follow-up visit two months later, she exhibited no residual symptoms.

Study Author Conclusions

Delayed Psychosis Induced by Bupropion in a Former Cocaine Abuser: A Case Report

Design

Case presentation

A 47-year-old African American woman, diagnosed in 2007 with mild recurrent major depressive disorder, posttraumatic stress disorder, and cocaine abuse (in early full remission), began feeling depressed following her husband's recent colon cancer diagnosis 7 months before this report. She was hospitalized and prescribed escitalopram 20 mg and trazodone 50 mg at bedtime, as needed for insomnia. Additionally, five months prior, she returned to the clinic with significant improvement in her depressive symptoms but continued to experience low energy levels. She occasionally had flashbacks of her boyfriend being shot and witnessing relatives die in a fire. Despite some improvement, she remained withdrawn, lacked motivation, and struggled with sleep. Her trazodone dose was increased to 100 mg at bedtime as needed, and bupropion sustained release (SR) 100 mg BID daily was added to address low energy.

Two months later, the patient reported significant improvement with good energy levels, though she still experienced occasional flashbacks. She denied depressive, manic, psychotic, paranoid, or suicidal symptoms, and her sleep was stable with medication. However, four months after starting bupropion, she returned with increased paranoia, withdrawal, a feeling of being watched, and visual disturbances like seeing shadows. The patient also continued to have nightmares about past abuse. Suspecting bupropion-induced psychosis, bupropion was discontinued and paliperidone 3 mg daily was initiated. Consequently, her condition significantly improved two weeks later: she no longer saw shadows, denied paranoia or depression, and began leaving her home, though she remained somewhat hesitant and continued to have occasional nightmares.

Study Author Conclusions

Two Acute Psychotic Episodes After Administration of Bupropion: A Case of Involuntary Rechallenge

Design

Case presentation

A 31-year-old Caucasian woman with a history of schizoaffective disorder and significant smoking history had been stable on outpatient psychiatric care, including olanzapine 10 mg daily and alprazolam 0.25 mg twice daily. Her previous psychiatric history included a three-month hospitalization for acute delirium and mania, but she had remained stable until recently.

During her first acute delirium episode, the patient was admitted for acute psychomotor agitation after starting bupropion SR (150 mg/day) as part of a smoking cessation program. She had begun the medication two days prior to her hospitalization. Upon admission, she exhibited persecutory delusions, dissociative symptoms, and aggressive behavior. Laboratory results were inconclusive. Bupropion was discontinued, and her treatment regimen was adjusted to include olanzapine 20 mg daily, cyamemazine 30 mg three times daily, and alprazolam 0.5 mg three times daily. Despite initial resistance and delusions of poisoning, her condition improved with as-needed loxapine injections. She was discharged after 12 days, with a reduced olanzapine dose of 5 mg daily and alprazolam 0.25 mg twice daily.

One month later, the patient was readmitted with severe agitation, delusions of persecution, and manic symptoms, including pressured speech, flight of ideas, and pronounced aggressiveness. A family interview revealed she had resumed bupropion SR (150 mg/day) four days before this episode, against medical advice. Her treatment was adjusted to olanzapine 20 mg daily, clonazepam 2 mg three times daily, and divalproate 2.5 g daily. Her condition stabilized over 15 days, and she was discharged after a month of hospitalization. Bupropion was permanently discontinued, and she remained stable without recurrence of psychotic symptoms during the following seven months.

Study Author Conclusions

This case is a reminder that a great amount of caution is needed when starting treatment with bupropion, especially in patients with a history of psychotic episodes.

To our knowledge, this is the first reported case of involuntary rechallenge during treatment with bupropion that has induced two acute psychotic episodes.