Bupropion-Associated Withdrawal Symptoms: A Case Report

[Guest guest]

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC181057/

Bupropion-Associated Withdrawal Symptoms: A Case Report

R. Berigan, D.D.S., M.D. and S. Harazin, M.D.

From the Division Mental Health 82D, U.S. Army Medical Command, Fort Bragg, N.C.

Reprint requests to: R. Berigan, D.D.S., M.D., 50 Bassett St., Fort

Bragg, NC 28307.

Received February 10, 1999; Accepted March 11, 1999.

This article has been cited by other articles in PMC.

Abstract

Withdrawal symptoms associated with the cessation of therapy have been widely

described for most antidepressants. The authors report irritable mood, anxiety,

sleeplessness, headache, and generalized aches and pains associated with the

abrupt discontinuation of bupropion treatment in a 32-year-old man being treated

for nicotine dependence. The authors recommend a slow taper for antidepressant

discontinuation, along with vigilance for withdrawal symptoms and educating

patients to the benefits of compliance.

 

Discontinuation symptoms following cessation of antidepressant medication

therapy are widely described in the literature.1 The discontinuation symptoms

are associated with most antidepressants including tricyclic antidepressants

(TCAs), monoamine oxidase inhibitors (MAOIs), and selective serotonin reuptake

inhibitors (SSRIs).2 Published reports also describe withdrawal symptoms

following cessation of venlafaxine,3 nefazodone,4 and mirtazapine.5 We describe

withdrawal symptoms associated with abrupt discontinuation of bupropion, which,

to our knowledge, have not been previously described in the literature.

 Other Sections▼

Mr. A, a 32-year-old man who had a 12-year history of smoking 1 pack per day,

was diagnosed with DSM-IV nicotine dependence and enrolled in a tobacco

cessation program. He suffered from no psychiatric illness and was in good

physical condition despite his nicotine habit. At the time of his enrollment

into the tobacco cessation program, he admitted to an occasional glass of wine

with dinner, 1 or 2 cups of coffee in the morning, and no use of illicit

substances. He was not taking any prescription medications but took an

occasional ibuprofen for minor aches and pains.

Mr. A had made at least 4 attempts to quit in the previous 2 years by abrupt

cessation (cold turkey). No attempt lasted more than 3 days, with Mr. A citing

“stress†as the reason for his lack of success. As part of the tobacco

cessation program, he participated in group behavioral modification sessions and

started a course of bupropion sustained-release (SR), 150 mg/day, for the first

3 days, increased to 150 mg b.i.d. to be taken for 10 weeks. By day 3, he noted

a decrease in his nicotine cravings and did not report any adverse effects

associated with bupropion. Mr. A quit smoking 3 weeks after starting bupropion

as per his self-disclosure in the group setting that coincided with week 2 of a

total of 4 sessions of face-to-face counseling. He completed the 4 one-hour

sessions and was to take bupropion for 4 more weeks and taper off over the last

week, taking 150 mg one time per day and then stopping the medication. Sometime

during the eighth week after initiating bupropion therapy, he inadvertently

stopped his medication with no apparent immediate problems. However, about 5

days after stopping the medication, he noticed an irritable mood, an anxious

feeling, an inability to sleep, headache, and generalized aches and pains. The

patient, thinking he had the flu, went to see his primary care physician. His

physician also felt he had the flu and recommended he stay home from work,

thereby missing a day and a half of work.

In a routine telephone follow-up call made as part of the tobacco cessation

program, Mr. A explained his constellation of symptoms and was asked to come in

for follow-up. At that time, he had been tobacco-free for approximately 8 weeks.

A review of his medical record from a recent visit to his primary care physician

showed that results of a complete blood count, chemistry 10, and urine analysis

were all within normal limits, and his vital signs were unremarkable. Thinking

that these symptoms could be related to the abrupt withdrawal of bupropion, we

decided to restart bupropion SR at 150 mg/day. By 36 hours, the patient's

symptoms had resolved and he tapered off bupropion SR, taking 150 mg/day for 4

days followed by 150 mg every other day for 8 days (4 total doses) and 150 mg

every third day for 6 days (2 total doses) without further complications. Mr. A

remains tobacco free at 7 months, again based on his honest self-disclosure.

 Other Sections▼

It is known that sudden and even tapered withdrawal from antidepressants can

cause a variety of somatic and psychological symptoms.6 Although the exact

mechanism is not known, it is postulated that the discontinuation phenomena may

be due to decreased availability of synaptic serotonin and that other

neurotransmitters such as dopamine, norepinephrine, and γ-aminobutyric acid

(GABA) may be involved, as well as cholinergic rebound.7 Although bupropion has

no effect on the serotonin system and lacks anticholinergic activity, its

mechanism of action, mediated through the dopaminergic and noradrenergic

systems,8 may have contributed to our patient's discontinuation symptoms.

Pollock1 states that all SSRIs should be gradually tapered to minimize the

possibility of discontinuation symptoms. On the basis of our experience, until

the discontinuation or withdrawal syndrome is more clearly defined, we recommend

a slow taper of the antidepressant during discontinuation, regardless of the

half-life or mechanism of action. As more physicians prescribe antidepressants

for a myriad of clinical entities, they need to remain alert for withdrawal

symptoms and work in educating patients to the possibility of discontinuation

symptoms. This type of education will not only increase compliance but also

decrease the abrupt discontinuation of antidepressants by patients.

Drug names: bupropion (Zyban), ibuprofen (Motrin and others), mirtazapine

(Remeron), nefazodone (Serzone), venlafaxine (Effexor).

Footnotes

Conclusions and opinions expressed are those of the authors and do not

necessarily reflect the position or policy of the U.S. Government, Department of

Defense, Department of the Army, U.S. Army Medical Command, Department of

Veteran's Affairs, or the 82D Airborne Division.

REFERENCES

Pollock BG. Discontinuation symptoms and SSRIs [letter with reply] J Clin

Psychiatry. 1998;59:535–536. [PubMed]

Tollefson GD, Rosenbaum JF. Selective serotonin reuptake inhibitors. In:

Schatzberg AF, Nemeroff CB, eds. The American Psychiatric Press Textbook of

Psychopharmacology. 2nd ed. Washington, DC: American Psychiatric Press. 1998.

 219–237.

Fava M, Mulroy R, Alpert J, et al. Emergence of adverse events following

discontinuation of treatment with extended-release venlafaxine. Am J Psychiatry.

1997;154:1760–1762. [PubMed]

Benazzi F. Nefazodone withdrawal symptoms. Can J Psychiatry. 1998;43:194–195.

[PubMed]

Benazzi F. Mirtazapine withdrawal symptoms. Can J Psychiatry. 1998;43:525.

Lejoyeaux M, Ades J. Antidepressant discontinuation: a review of the literature.

J Clin Psychiatry. 1997;58(suppl 7):11–16.

Schatzberg AF, Haddad P, Kaplan EM, et al. Possible biological mechanisms of the

serotonin reuptake inhibitor discontinuation syndrome. J Clin Psychiatry.

1997;58(suppl 7):23–27. [PubMed]

Golden RN, Dawkins K, L, and et al. Trazodone, nefazodone, bupropion

and mirtazapine. In: Schatzberg AF, Nemeroff CB, eds. The American Psychiatric

Press Textbook of Psychopharmacology. 2nd ed. Washington, DC: American

Psychiatric Press. 1998.  251–269.

Articles from Primary Care Companion to The Journal of Clinical Psychiatry are

provided here courtesy of

Physicians Postgraduate Press, Inc.

Sent via BlackBerry by AT & T

[Guest guest]

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC181057/

Bupropion-Associated Withdrawal Symptoms: A Case Report

R. Berigan, D.D.S., M.D. and S. Harazin, M.D.

From the Division Mental Health 82D, U.S. Army Medical Command, Fort Bragg, N.C.

Reprint requests to: R. Berigan, D.D.S., M.D., 50 Bassett St., Fort

Bragg, NC 28307.

Received February 10, 1999; Accepted March 11, 1999.

This article has been cited by other articles in PMC.

Abstract

Withdrawal symptoms associated with the cessation of therapy have been widely

described for most antidepressants. The authors report irritable mood, anxiety,

sleeplessness, headache, and generalized aches and pains associated with the

abrupt discontinuation of bupropion treatment in a 32-year-old man being treated

for nicotine dependence. The authors recommend a slow taper for antidepressant

discontinuation, along with vigilance for withdrawal symptoms and educating

patients to the benefits of compliance.

 

Discontinuation symptoms following cessation of antidepressant medication

therapy are widely described in the literature.1 The discontinuation symptoms

are associated with most antidepressants including tricyclic antidepressants

(TCAs), monoamine oxidase inhibitors (MAOIs), and selective serotonin reuptake

inhibitors (SSRIs).2 Published reports also describe withdrawal symptoms

following cessation of venlafaxine,3 nefazodone,4 and mirtazapine.5 We describe

withdrawal symptoms associated with abrupt discontinuation of bupropion, which,

to our knowledge, have not been previously described in the literature.

 Other Sections▼

Mr. A, a 32-year-old man who had a 12-year history of smoking 1 pack per day,

was diagnosed with DSM-IV nicotine dependence and enrolled in a tobacco

cessation program. He suffered from no psychiatric illness and was in good

physical condition despite his nicotine habit. At the time of his enrollment

into the tobacco cessation program, he admitted to an occasional glass of wine

with dinner, 1 or 2 cups of coffee in the morning, and no use of illicit

substances. He was not taking any prescription medications but took an

occasional ibuprofen for minor aches and pains.

Mr. A had made at least 4 attempts to quit in the previous 2 years by abrupt

cessation (cold turkey). No attempt lasted more than 3 days, with Mr. A citing

“stress†as the reason for his lack of success. As part of the tobacco

cessation program, he participated in group behavioral modification sessions and

started a course of bupropion sustained-release (SR), 150 mg/day, for the first

3 days, increased to 150 mg b.i.d. to be taken for 10 weeks. By day 3, he noted

a decrease in his nicotine cravings and did not report any adverse effects

associated with bupropion. Mr. A quit smoking 3 weeks after starting bupropion

as per his self-disclosure in the group setting that coincided with week 2 of a

total of 4 sessions of face-to-face counseling. He completed the 4 one-hour

sessions and was to take bupropion for 4 more weeks and taper off over the last

week, taking 150 mg one time per day and then stopping the medication. Sometime

during the eighth week after initiating bupropion therapy, he inadvertently

stopped his medication with no apparent immediate problems. However, about 5

days after stopping the medication, he noticed an irritable mood, an anxious

feeling, an inability to sleep, headache, and generalized aches and pains. The

patient, thinking he had the flu, went to see his primary care physician. His

physician also felt he had the flu and recommended he stay home from work,

thereby missing a day and a half of work.

In a routine telephone follow-up call made as part of the tobacco cessation

program, Mr. A explained his constellation of symptoms and was asked to come in

for follow-up. At that time, he had been tobacco-free for approximately 8 weeks.

A review of his medical record from a recent visit to his primary care physician

showed that results of a complete blood count, chemistry 10, and urine analysis

were all within normal limits, and his vital signs were unremarkable. Thinking

that these symptoms could be related to the abrupt withdrawal of bupropion, we

decided to restart bupropion SR at 150 mg/day. By 36 hours, the patient's

symptoms had resolved and he tapered off bupropion SR, taking 150 mg/day for 4

days followed by 150 mg every other day for 8 days (4 total doses) and 150 mg

every third day for 6 days (2 total doses) without further complications. Mr. A

remains tobacco free at 7 months, again based on his honest self-disclosure.

 Other Sections▼

It is known that sudden and even tapered withdrawal from antidepressants can

cause a variety of somatic and psychological symptoms.6 Although the exact

mechanism is not known, it is postulated that the discontinuation phenomena may

be due to decreased availability of synaptic serotonin and that other

neurotransmitters such as dopamine, norepinephrine, and γ-aminobutyric acid

(GABA) may be involved, as well as cholinergic rebound.7 Although bupropion has

no effect on the serotonin system and lacks anticholinergic activity, its

mechanism of action, mediated through the dopaminergic and noradrenergic

systems,8 may have contributed to our patient's discontinuation symptoms.

Pollock1 states that all SSRIs should be gradually tapered to minimize the

possibility of discontinuation symptoms. On the basis of our experience, until

the discontinuation or withdrawal syndrome is more clearly defined, we recommend

a slow taper of the antidepressant during discontinuation, regardless of the

half-life or mechanism of action. As more physicians prescribe antidepressants

for a myriad of clinical entities, they need to remain alert for withdrawal

symptoms and work in educating patients to the possibility of discontinuation

symptoms. This type of education will not only increase compliance but also

decrease the abrupt discontinuation of antidepressants by patients.

Drug names: bupropion (Zyban), ibuprofen (Motrin and others), mirtazapine

(Remeron), nefazodone (Serzone), venlafaxine (Effexor).

Footnotes

Conclusions and opinions expressed are those of the authors and do not

necessarily reflect the position or policy of the U.S. Government, Department of

Defense, Department of the Army, U.S. Army Medical Command, Department of

Veteran's Affairs, or the 82D Airborne Division.

REFERENCES

Pollock BG. Discontinuation symptoms and SSRIs [letter with reply] J Clin

Psychiatry. 1998;59:535–536. [PubMed]

Tollefson GD, Rosenbaum JF. Selective serotonin reuptake inhibitors. In:

Schatzberg AF, Nemeroff CB, eds. The American Psychiatric Press Textbook of

Psychopharmacology. 2nd ed. Washington, DC: American Psychiatric Press. 1998.

 219–237.

Fava M, Mulroy R, Alpert J, et al. Emergence of adverse events following

discontinuation of treatment with extended-release venlafaxine. Am J Psychiatry.

1997;154:1760–1762. [PubMed]

Benazzi F. Nefazodone withdrawal symptoms. Can J Psychiatry. 1998;43:194–195.

[PubMed]

Benazzi F. Mirtazapine withdrawal symptoms. Can J Psychiatry. 1998;43:525.

Lejoyeaux M, Ades J. Antidepressant discontinuation: a review of the literature.

J Clin Psychiatry. 1997;58(suppl 7):11–16.

Schatzberg AF, Haddad P, Kaplan EM, et al. Possible biological mechanisms of the

serotonin reuptake inhibitor discontinuation syndrome. J Clin Psychiatry.

1997;58(suppl 7):23–27. [PubMed]

Golden RN, Dawkins K, L, and et al. Trazodone, nefazodone, bupropion

and mirtazapine. In: Schatzberg AF, Nemeroff CB, eds. The American Psychiatric

Press Textbook of Psychopharmacology. 2nd ed. Washington, DC: American

Psychiatric Press. 1998.  251–269.

Articles from Primary Care Companion to The Journal of Clinical Psychiatry are

provided here courtesy of

Physicians Postgraduate Press, Inc.

Sent via BlackBerry by AT & T

[Guest guest]

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC181057/

Bupropion-Associated Withdrawal Symptoms: A Case Report

R. Berigan, D.D.S., M.D. and S. Harazin, M.D.

From the Division Mental Health 82D, U.S. Army Medical Command, Fort Bragg, N.C.

Reprint requests to: R. Berigan, D.D.S., M.D., 50 Bassett St., Fort

Bragg, NC 28307.

Received February 10, 1999; Accepted March 11, 1999.

This article has been cited by other articles in PMC.

Abstract

Withdrawal symptoms associated with the cessation of therapy have been widely

described for most antidepressants. The authors report irritable mood, anxiety,

sleeplessness, headache, and generalized aches and pains associated with the

abrupt discontinuation of bupropion treatment in a 32-year-old man being treated

for nicotine dependence. The authors recommend a slow taper for antidepressant

discontinuation, along with vigilance for withdrawal symptoms and educating

patients to the benefits of compliance.

 

Discontinuation symptoms following cessation of antidepressant medication

therapy are widely described in the literature.1 The discontinuation symptoms

are associated with most antidepressants including tricyclic antidepressants

(TCAs), monoamine oxidase inhibitors (MAOIs), and selective serotonin reuptake

inhibitors (SSRIs).2 Published reports also describe withdrawal symptoms

following cessation of venlafaxine,3 nefazodone,4 and mirtazapine.5 We describe

withdrawal symptoms associated with abrupt discontinuation of bupropion, which,

to our knowledge, have not been previously described in the literature.

 Other Sections▼

Mr. A, a 32-year-old man who had a 12-year history of smoking 1 pack per day,

was diagnosed with DSM-IV nicotine dependence and enrolled in a tobacco

cessation program. He suffered from no psychiatric illness and was in good

physical condition despite his nicotine habit. At the time of his enrollment

into the tobacco cessation program, he admitted to an occasional glass of wine

with dinner, 1 or 2 cups of coffee in the morning, and no use of illicit

substances. He was not taking any prescription medications but took an

occasional ibuprofen for minor aches and pains.

Mr. A had made at least 4 attempts to quit in the previous 2 years by abrupt

cessation (cold turkey). No attempt lasted more than 3 days, with Mr. A citing

“stress†as the reason for his lack of success. As part of the tobacco

cessation program, he participated in group behavioral modification sessions and

started a course of bupropion sustained-release (SR), 150 mg/day, for the first

3 days, increased to 150 mg b.i.d. to be taken for 10 weeks. By day 3, he noted

a decrease in his nicotine cravings and did not report any adverse effects

associated with bupropion. Mr. A quit smoking 3 weeks after starting bupropion

as per his self-disclosure in the group setting that coincided with week 2 of a

total of 4 sessions of face-to-face counseling. He completed the 4 one-hour

sessions and was to take bupropion for 4 more weeks and taper off over the last

week, taking 150 mg one time per day and then stopping the medication. Sometime

during the eighth week after initiating bupropion therapy, he inadvertently

stopped his medication with no apparent immediate problems. However, about 5

days after stopping the medication, he noticed an irritable mood, an anxious

feeling, an inability to sleep, headache, and generalized aches and pains. The

patient, thinking he had the flu, went to see his primary care physician. His

physician also felt he had the flu and recommended he stay home from work,

thereby missing a day and a half of work.

In a routine telephone follow-up call made as part of the tobacco cessation

program, Mr. A explained his constellation of symptoms and was asked to come in

for follow-up. At that time, he had been tobacco-free for approximately 8 weeks.

A review of his medical record from a recent visit to his primary care physician

showed that results of a complete blood count, chemistry 10, and urine analysis

were all within normal limits, and his vital signs were unremarkable. Thinking

that these symptoms could be related to the abrupt withdrawal of bupropion, we

decided to restart bupropion SR at 150 mg/day. By 36 hours, the patient's

symptoms had resolved and he tapered off bupropion SR, taking 150 mg/day for 4

days followed by 150 mg every other day for 8 days (4 total doses) and 150 mg

every third day for 6 days (2 total doses) without further complications. Mr. A

remains tobacco free at 7 months, again based on his honest self-disclosure.

 Other Sections▼

It is known that sudden and even tapered withdrawal from antidepressants can

cause a variety of somatic and psychological symptoms.6 Although the exact

mechanism is not known, it is postulated that the discontinuation phenomena may

be due to decreased availability of synaptic serotonin and that other

neurotransmitters such as dopamine, norepinephrine, and γ-aminobutyric acid

(GABA) may be involved, as well as cholinergic rebound.7 Although bupropion has

no effect on the serotonin system and lacks anticholinergic activity, its

mechanism of action, mediated through the dopaminergic and noradrenergic

systems,8 may have contributed to our patient's discontinuation symptoms.

Pollock1 states that all SSRIs should be gradually tapered to minimize the

possibility of discontinuation symptoms. On the basis of our experience, until

the discontinuation or withdrawal syndrome is more clearly defined, we recommend

a slow taper of the antidepressant during discontinuation, regardless of the

half-life or mechanism of action. As more physicians prescribe antidepressants

for a myriad of clinical entities, they need to remain alert for withdrawal

symptoms and work in educating patients to the possibility of discontinuation

symptoms. This type of education will not only increase compliance but also

decrease the abrupt discontinuation of antidepressants by patients.

Drug names: bupropion (Zyban), ibuprofen (Motrin and others), mirtazapine

(Remeron), nefazodone (Serzone), venlafaxine (Effexor).

Footnotes

Conclusions and opinions expressed are those of the authors and do not

necessarily reflect the position or policy of the U.S. Government, Department of

Defense, Department of the Army, U.S. Army Medical Command, Department of

Veteran's Affairs, or the 82D Airborne Division.

REFERENCES

Pollock BG. Discontinuation symptoms and SSRIs [letter with reply] J Clin

Psychiatry. 1998;59:535–536. [PubMed]

Tollefson GD, Rosenbaum JF. Selective serotonin reuptake inhibitors. In:

Schatzberg AF, Nemeroff CB, eds. The American Psychiatric Press Textbook of

Psychopharmacology. 2nd ed. Washington, DC: American Psychiatric Press. 1998.

 219–237.

Fava M, Mulroy R, Alpert J, et al. Emergence of adverse events following

discontinuation of treatment with extended-release venlafaxine. Am J Psychiatry.

1997;154:1760–1762. [PubMed]

Benazzi F. Nefazodone withdrawal symptoms. Can J Psychiatry. 1998;43:194–195.

[PubMed]

Benazzi F. Mirtazapine withdrawal symptoms. Can J Psychiatry. 1998;43:525.

Lejoyeaux M, Ades J. Antidepressant discontinuation: a review of the literature.

J Clin Psychiatry. 1997;58(suppl 7):11–16.

Schatzberg AF, Haddad P, Kaplan EM, et al. Possible biological mechanisms of the

serotonin reuptake inhibitor discontinuation syndrome. J Clin Psychiatry.

1997;58(suppl 7):23–27. [PubMed]

Golden RN, Dawkins K, L, and et al. Trazodone, nefazodone, bupropion

and mirtazapine. In: Schatzberg AF, Nemeroff CB, eds. The American Psychiatric

Press Textbook of Psychopharmacology. 2nd ed. Washington, DC: American

Psychiatric Press. 1998.  251–269.

Articles from Primary Care Companion to The Journal of Clinical Psychiatry are

provided here courtesy of

Physicians Postgraduate Press, Inc.

Sent via BlackBerry by AT & T

[Guest guest]

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC181057/

Bupropion-Associated Withdrawal Symptoms: A Case Report

R. Berigan, D.D.S., M.D. and S. Harazin, M.D.

From the Division Mental Health 82D, U.S. Army Medical Command, Fort Bragg, N.C.

Reprint requests to: R. Berigan, D.D.S., M.D., 50 Bassett St., Fort

Bragg, NC 28307.

Received February 10, 1999; Accepted March 11, 1999.

This article has been cited by other articles in PMC.

Abstract

Withdrawal symptoms associated with the cessation of therapy have been widely

described for most antidepressants. The authors report irritable mood, anxiety,

sleeplessness, headache, and generalized aches and pains associated with the

abrupt discontinuation of bupropion treatment in a 32-year-old man being treated

for nicotine dependence. The authors recommend a slow taper for antidepressant

discontinuation, along with vigilance for withdrawal symptoms and educating

patients to the benefits of compliance.

 

Discontinuation symptoms following cessation of antidepressant medication

therapy are widely described in the literature.1 The discontinuation symptoms

are associated with most antidepressants including tricyclic antidepressants

(TCAs), monoamine oxidase inhibitors (MAOIs), and selective serotonin reuptake

inhibitors (SSRIs).2 Published reports also describe withdrawal symptoms

following cessation of venlafaxine,3 nefazodone,4 and mirtazapine.5 We describe

withdrawal symptoms associated with abrupt discontinuation of bupropion, which,

to our knowledge, have not been previously described in the literature.

 Other Sections▼

Mr. A, a 32-year-old man who had a 12-year history of smoking 1 pack per day,

was diagnosed with DSM-IV nicotine dependence and enrolled in a tobacco

cessation program. He suffered from no psychiatric illness and was in good

physical condition despite his nicotine habit. At the time of his enrollment

into the tobacco cessation program, he admitted to an occasional glass of wine

with dinner, 1 or 2 cups of coffee in the morning, and no use of illicit

substances. He was not taking any prescription medications but took an

occasional ibuprofen for minor aches and pains.

Mr. A had made at least 4 attempts to quit in the previous 2 years by abrupt

cessation (cold turkey). No attempt lasted more than 3 days, with Mr. A citing

“stress†as the reason for his lack of success. As part of the tobacco

cessation program, he participated in group behavioral modification sessions and

started a course of bupropion sustained-release (SR), 150 mg/day, for the first

3 days, increased to 150 mg b.i.d. to be taken for 10 weeks. By day 3, he noted

a decrease in his nicotine cravings and did not report any adverse effects

associated with bupropion. Mr. A quit smoking 3 weeks after starting bupropion

as per his self-disclosure in the group setting that coincided with week 2 of a

total of 4 sessions of face-to-face counseling. He completed the 4 one-hour

sessions and was to take bupropion for 4 more weeks and taper off over the last

week, taking 150 mg one time per day and then stopping the medication. Sometime

during the eighth week after initiating bupropion therapy, he inadvertently

stopped his medication with no apparent immediate problems. However, about 5

days after stopping the medication, he noticed an irritable mood, an anxious

feeling, an inability to sleep, headache, and generalized aches and pains. The

patient, thinking he had the flu, went to see his primary care physician. His

physician also felt he had the flu and recommended he stay home from work,

thereby missing a day and a half of work.

In a routine telephone follow-up call made as part of the tobacco cessation

program, Mr. A explained his constellation of symptoms and was asked to come in

for follow-up. At that time, he had been tobacco-free for approximately 8 weeks.

A review of his medical record from a recent visit to his primary care physician

showed that results of a complete blood count, chemistry 10, and urine analysis

were all within normal limits, and his vital signs were unremarkable. Thinking

that these symptoms could be related to the abrupt withdrawal of bupropion, we

decided to restart bupropion SR at 150 mg/day. By 36 hours, the patient's

symptoms had resolved and he tapered off bupropion SR, taking 150 mg/day for 4

days followed by 150 mg every other day for 8 days (4 total doses) and 150 mg

every third day for 6 days (2 total doses) without further complications. Mr. A

remains tobacco free at 7 months, again based on his honest self-disclosure.

 Other Sections▼

It is known that sudden and even tapered withdrawal from antidepressants can

cause a variety of somatic and psychological symptoms.6 Although the exact

mechanism is not known, it is postulated that the discontinuation phenomena may

be due to decreased availability of synaptic serotonin and that other

neurotransmitters such as dopamine, norepinephrine, and γ-aminobutyric acid

(GABA) may be involved, as well as cholinergic rebound.7 Although bupropion has

no effect on the serotonin system and lacks anticholinergic activity, its

mechanism of action, mediated through the dopaminergic and noradrenergic

systems,8 may have contributed to our patient's discontinuation symptoms.

Pollock1 states that all SSRIs should be gradually tapered to minimize the

possibility of discontinuation symptoms. On the basis of our experience, until

the discontinuation or withdrawal syndrome is more clearly defined, we recommend

a slow taper of the antidepressant during discontinuation, regardless of the

half-life or mechanism of action. As more physicians prescribe antidepressants

for a myriad of clinical entities, they need to remain alert for withdrawal

symptoms and work in educating patients to the possibility of discontinuation

symptoms. This type of education will not only increase compliance but also

decrease the abrupt discontinuation of antidepressants by patients.

Drug names: bupropion (Zyban), ibuprofen (Motrin and others), mirtazapine

(Remeron), nefazodone (Serzone), venlafaxine (Effexor).

Footnotes

Conclusions and opinions expressed are those of the authors and do not

necessarily reflect the position or policy of the U.S. Government, Department of

Defense, Department of the Army, U.S. Army Medical Command, Department of

Veteran's Affairs, or the 82D Airborne Division.

REFERENCES

Pollock BG. Discontinuation symptoms and SSRIs [letter with reply] J Clin

Psychiatry. 1998;59:535–536. [PubMed]

Tollefson GD, Rosenbaum JF. Selective serotonin reuptake inhibitors. In:

Schatzberg AF, Nemeroff CB, eds. The American Psychiatric Press Textbook of

Psychopharmacology. 2nd ed. Washington, DC: American Psychiatric Press. 1998.

 219–237.

Fava M, Mulroy R, Alpert J, et al. Emergence of adverse events following

discontinuation of treatment with extended-release venlafaxine. Am J Psychiatry.

1997;154:1760–1762. [PubMed]

Benazzi F. Nefazodone withdrawal symptoms. Can J Psychiatry. 1998;43:194–195.

[PubMed]

Benazzi F. Mirtazapine withdrawal symptoms. Can J Psychiatry. 1998;43:525.

Lejoyeaux M, Ades J. Antidepressant discontinuation: a review of the literature.

J Clin Psychiatry. 1997;58(suppl 7):11–16.

Schatzberg AF, Haddad P, Kaplan EM, et al. Possible biological mechanisms of the

serotonin reuptake inhibitor discontinuation syndrome. J Clin Psychiatry.

1997;58(suppl 7):23–27. [PubMed]

Golden RN, Dawkins K, L, and et al. Trazodone, nefazodone, bupropion

and mirtazapine. In: Schatzberg AF, Nemeroff CB, eds. The American Psychiatric

Press Textbook of Psychopharmacology. 2nd ed. Washington, DC: American

Psychiatric Press. 1998.  251–269.

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