Bupropion as add-on strategy in difficult-to-treat bipolar depressive patients

Bupropion, a selective norepinephrine and dopamine reuptake inhibitor, has been suggested for the treatment of bipolar depression, not only because of its efficacy, but also because of a probably lower risk of inducing switches to hypomania or mania. Most studies on bupropion treatment in bipolar patients have been performed in moderately ill out-patients. In contrast, we report on a sample of difficult-to-treat, predominantly severely ill, co-morbid, psychotic or therapy-refractory bipolar depressive in-patients. In this open and prospective study, 13 patients were treated with bupropion as an add-on strategy mainly to other antidepressants and to various mood stabilizers. Our data support the idea that bupropion is a first-line antidepressant in the treatment of severe bipolar depression. Eight of 13 patients showed a >50% reduction of Montgomery-Asberg Depression Scale ratings within 4 weeks. Co-medication with drugs commonly used in treatment-resistant bipolar disorder including venlafaxine, clozapine, lithium, topiramate and sodium valproate was safe in our small sample. While adhering to the suggestion of Goren and Levin not to exceed a daily dose of 450 mg of bupropion when treating bipolar depressed patients, we did not observe any switch from depression to hypomania or mania.