Bupropion for Anxiety Treatment

Key Clinical Considerations

Bupropion is not recommended as a first-line treatment for primary anxiety disorders, but it can be safely used in patients with comorbid depression and anxiety, where it demonstrates comparable anxiolytic efficacy to SSRIs, according to the American College of Cardiology 1
The American College of Cardiology recommends avoiding bupropion in patients with severe anxiety, as the stimulating properties of bupropion can provoke or worsen anxiety, particularly at higher doses 1
Absolute contraindications for bupropion include seizure disorders, history of seizures, conditions predisposing to seizures, and concurrent MAOI use, as stated by the American Academy of Neurology 2
The American Heart Association recommends using bupropion with caution in patients with uncontrolled hypertension, moderate-to-severe hepatic or renal impairment, and bipolar disorder, due to the potential for increased risk of adverse effects 1, 3

The initial dose of bupropion should be 150 mg once daily for 3 days, with a maintenance dose of 150 mg twice daily, and a maximum dose of 300 mg/day to minimize seizure risk and anxiogenic effects, as recommended by the American Psychiatric Association 3
The American Academy of Family Physicians suggests administering the second dose of bupropion before 3 p.m. to minimize insomnia 3

Bupropion may be chosen when a patient has comorbid depression and mild-to-moderate anxiety, weight gain is a concern, or the patient wants to quit smoking concurrently, as stated by the American College of Cardiology 1, 3
The American Academy of Neurology recommends avoiding bupropion when the primary diagnosis is severe anxiety disorder without depression, or when the patient has a seizure history or risk factors 2

The American Heart Association recommends assessing anxiety severity at baseline, 6 weeks, and 12 weeks using standardized scales, and monitoring for anxiogenic symptoms during the first 2-4 weeks, particularly after dose increases 3
The American Psychiatric Association suggests checking blood pressure regularly and watching for neuropsychiatric adverse effects, especially in patients under 24 years old 3

Bupropion is FDA‑approved for the treatment of major depressive disorder and for smoking cessation; it is not approved for anxiety disorders alone and may worsen anxiety symptoms, especially at higher doses. 4, 5
As a second‑generation antidepressant, bupropion is considered appropriate for first‑line therapy of major depressive disorder, showing efficacy comparable to selective serotonin reuptake inhibitors such as escitalopram and sertraline. 4, 5
The American College of Physicians includes bupropion among twelve second‑generation antidepressants recommended for the acute, continuation, and maintenance phases of major depressive disorder and dysthymia. 4, 5

Bupropion should not be used as monotherapy when the primary clinical presentation is an anxiety disorder without significant depressive symptoms, because its dopaminergic and noradrenergic activating properties can exacerbate anxiety, agitation, and restlessness. 6