Sir: Previously in the Companion, a case of bupropion-associated withdrawal symptoms had been described.1 That case report was followed with a reply from Dr. Johnston of Glaxo Wellcome Inc., who could not establish a relationship between bupropion cessation and withdrawal symptoms.2 Since that time I have observed another case of bupropion-associated withdrawal symptoms.
Case report. Ms. A was a 27-year-old African American woman diagnosed with a major depressive episode, which was moderate in accordance with DSM-IV criteria. She also had a significant smoking history of 1 to 2 packs per day since the age of 17. Prior to initiating antidepressant therapy, she scored a 28 on the Hamilton Rating Scale for Depression (HAM-D).3 She was started on venlafaxine extended release (XR) at 37.5 mg/day without any noted side effects. Her dose was increased to 150 mg/day over the next 2 weeks. Ms. A's score on the HAM-D after 1 month on venlafaxine XR treatment was 11. Subsequently, she saw a primary care physician who started her on bupropion sustained release (SR), 150 mg b.i.d., for smoking cessation. The patient remained on bupropion treatment for 4 months but had not stopped smoking. Within a day of stopping the bupropion therapy, she began to feel irritable and anxious. She had a headache and generalized aches and pains and, in her words, felt like she “wanted to crawl out of” her skin. The bupropion treatment was restarted, and her symptoms resolved within a day.
This case highlights the possibility that as more and more patients are prescribed antidepressants for a number of reasons, clinicians must be vigilant to the possibility of withdrawal symptoms. Bupropion is recognized as an important pharmacologic intervention in the treatment of smoking cessation and is generally well tolerated.4 However, it may be best to taper bupropion to avoid the possibility of withdrawal symptoms.
Conclusions and opinions expressed are those of the author and do not necessarily reflect the position or policy of the U.S. Government, Department of Defense, Department of the Army, or the U.S. Army Medical Command. This case occurred while Dr. Berigan was working at William Beaumont Army Medical Center in El Paso, Texas.
References
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