Introduction to bupropion
Bupropion is a prescription medication that belongs to a class of drugs known as aminoketones. It is primarily used to treat major depressive disorder and to help people quit smoking. Unlike many other antidepressants, Bupropion does not belong to the selective serotonin reuptake inhibitor (SSRI) or serotonin-norepinephrine reuptake inhibitor (SNRI) classes. Instead, it works by affecting the levels of norepinephrine and dopamine in the brain. This unique mechanism of action makes Bupropion a valuable option for patients who do not respond well to other antidepressants or who experience undesirable side effects from them. Bupropion is available under several brand names, including Wellbutrin, Zyban, and Aplenzin. The medication is taken orally, usually in tablet form, and is available in immediate-release, sustained-release, and extended-release formulations. Each formulation is designed to release the active ingredient at different rates, allowing for once-daily or twice-daily dosing depending on the patient’s needs.
Bupropion has been approved by the U.S. Food and Drug Administration (FDA) since 1985. Over the decades, it has become one of the most widely prescribed antidepressants in the United States. Its popularity stems not only from its effectiveness and from its relatively favorable side effect profile. Unlike SSRIs, Bupropion is less likely to cause sexual dysfunction or weight gain, two common reasons why patients discontinue antidepressant therapy. However, Bupropion does carry a risk of seizures, particularly at higher doses, which requires careful dose management by healthcare providers. Understanding how Bupropion works, its benefits, risks, and proper usage is essential for anyone considering this medication as part of their treatment plan. This comprehensive guide will walk you through everything you need to know about Bupropion, including its mechanism of action, approved and off-label uses, dosage guidelines, potential side effects, drug interactions, and much more.
How bupropion works in the brain
Bupropion is a norepinephrine-dopamine reuptake inhibitor (NDRI). This means it works by blocking the reabsorption (reuptake) of the neurotransmitters norepinephrine and dopamine in the brain. Neurotransmitters are chemical messengers that transmit signals between nerve cells. By preventing their reuptake, Bupropion increases the levels of these neurotransmitters in the synaptic cleft, the small gap between neurons where communication occurs. Higher levels of norepinephrine and dopamine lead to improved mood, increased energy, and enhanced focus and concentration. Norepinephrine is associated with alertness and energy, while dopamine plays a key role in pleasure, motivation, and reward pathways. This dual action is what sets Bupropion apart from other antidepressants that primarily target serotonin.
In addition to its effects on norepinephrine and dopamine, Bupropion also acts as a nicotinic acetylcholine receptor antagonist. This means it blocks the effects of nicotine at certain receptor sites in the brain. This property is what makes Bupropion effective for smoking cessation. By blocking the rewarding effects of nicotine, Bupropion reduces cravings and withdrawal symptoms, making it easier for individuals to quit smoking. The combination of its effects on both the dopamine reward system and nicotinic receptors makes Bupropion uniquely suited for this purpose. Bupropion does not contain nicotine and is not a nicotine replacement therapy. Instead, it works on the brain’s chemistry to reduce the desire to smoke. The exact mechanisms by which Bupropion exerts its antidepressant and smoking cessation effects are not fully understood, but the inhibition of norepinephrine and dopamine reuptake is believed to be central to its therapeutic actions.
Approved medical uses of bupropion
Major depressive disorder
The most common use of Bupropion is for the treatment of major depressive disorder (MDD). MDD involves persistent feelings of sadness, hopelessness, loss of interest in activities, changes in appetite and sleep patterns, and difficulty concentrating. Clinical studies have shown that Bupropion is as effective as SSRIs and SNRIs for treating depression. One advantage of Bupropion is that it tends to cause less sexual dysfunction than other antidepressants. Sexual side effects are a leading cause of non-adherence to antidepressant therapy, making Bupropion a preferred option for many patients. Bupropion is also less likely to cause weight gain, which is another common reason patients switch medications. Some patients even experience modest weight loss while taking Bupropion.
For the treatment of depression, Bupropion is typically started at a low dose and gradually increased to minimize side effects. The immediate-release formulation is usually taken three times a day, while the sustained-release formulation is taken twice daily, and the extended-release formulation is taken once daily. It may take several weeks for the full antidepressant effects of Bupropion to become apparent. Patients are advised to continue taking the medication as prescribed even if they do not notice immediate improvement. Abruptly stopping Bupropion can lead to withdrawal symptoms, so any discontinuation should be done under the guidance of a healthcare provider. The duration of treatment for MDD varies depending on the individual, but long-term maintenance therapy is often recommended to prevent relapse.
Seasonal affective disorder
Bupropion extended-release (Wellbutrin XL) is also approved for the prevention of seasonal affective disorder (SAD). SAD is a type of depression that occurs during specific seasons, typically fall and winter, when there is less natural sunlight. The condition involves symptoms such as fatigue, oversleeping, weight gain, and social withdrawal. Bupropion is taken prophylactically starting in the autumn before symptoms begin and continuing through the winter months. Studies have shown that Bupropion reduces the risk of developing SAD episodes when taken in this manner. The exact mechanism by which Bupropion prevents SAD is not fully understood, but it is believed to involve its effects on circadian rhythms and neurotransmitter levels that are affected by reduced sunlight exposure.
Smoking cessation
Bupropion is sold under the brand name Zyban for smoking cessation. It is used to help people stop smoking by reducing nicotine cravings and withdrawal symptoms. The medication is typically started one to two weeks before the target quit date to allow it to reach effective levels in the bloodstream. Patients continue taking Bupropion for seven to twelve weeks after quitting. The combination of Bupropion with behavioral counseling and support programs has been shown to increase the chances of successfully quitting smoking. Bupropion is particularly effective for smokers who have tried to quit using other methods without success. Bupropion works for smoking cessation through multiple mechanisms. First, it reduces the severity of nicotine cravings and withdrawal symptoms, including irritability, anxiety, difficulty concentrating, and restlessness. Second, it reduces the pleasurable effects of nicotine by blocking nicotinic acetylcholine receptors in the brain. This means that if a patient does smoke while taking Bupropion, the cigarette is less satisfying, which helps reduce the reinforcement of smoking behavior. Third, by increasing dopamine levels, Bupropion may help replace some of the mood-enhancing effects that the patient previously obtained from nicotine. Clinical studies have shown that Bupropion approximately doubles the chances of successfully quitting smoking compared to placebo.
Off-label uses of bupropion
In addition to its FDA-approved indications, Bupropion is sometimes prescribed off-label for other conditions. Off-label use refers to the prescription of a medication for a purpose not officially approved by regulatory agencies. While these uses may be supported by clinical evidence, they have not undergone the rigorous approval process required for formal indications. One common off-label use of Bupropion is for attention deficit hyperactivity disorder (ADHD). While not a first-line treatment, Bupropion can be effective for some patients, particularly those who cannot tolerate stimulant medications or who have co-occurring depression. Bupropion may improve attention, focus, and impulse control in individuals with ADHD.
Bupropion is also sometimes used to treat sexual dysfunction caused by SSRIs. Since Bupropion does not negatively affect sexual function and may even enhance libido, it can be added to A SSRI regimen to counteract sexual side effects. This approach, known as augmentation, involves adding Bupropion to an existing antidepressant treatment. Another off-label use is for bipolar depression, although this is controversial due to the risk of triggering manic episodes. Bupropion is generally considered safer than some other antidepressants for bipolar depression because it has a lower risk of causing mood switching. However, it should only be used in combination with a mood stabilizer in patients with bipolar disorder. Other off-label uses include treatment for obesity (sometimes in combination with naltrexone), neuropathic pain, and certain anxiety disorders, although the evidence for these uses varies.
Dosage forms and strengths
Bupropion is available in several different formulations, each with its own dosing schedule. The immediate-release (IR) formulation is the fastest-acting and is typically taken three or four times a day. This formulation is available in 75 mg and 100 mg tablets. The sustained-release (SR) formulation is designed to release the medication more slowly and is usually taken twice a day. It is available in 100 mg, 150 mg, and 200 mg tablets. The extended-release (XL) formulation is the longest-acting and is taken once daily. It is available in 150 mg, 300 mg, and 450 mg tablets. The choice of formulation depends on the condition being treated, the patient’s medical history, and their response to treatment. The extended-release formulation is often preferred because of its convenience and potentially lower risk of side effects due to more stable blood levels.
For the treatment of depression, the typical starting dose of Bupropion IR is 100 mg twice daily, which may be increased to 100 mg three times daily after several days. For the SR formulation, the starting dose is usually 150 mg once daily, increasing to 150 mg twice daily. For the XL formulation, the starting dose is 150 mg once daily, which can be increased to 300 mg once daily after several days. The maximum recommended dose for all formulations is 450 mg per day, although some patients may require lower doses due to side effects or medical conditions. For smoking cessation, the recommended dose is 150 mg once daily for the first three days, then 150 mg twice daily for the remainder of the treatment period. The maximum dose for smoking cessation is 300 mg per day. It is important to follow the prescribed dosing schedule carefully and not to exceed the recommended dose due to the risk of seizures.
Side effects of bupropion
Common side effects
Like all medications, Bupropion can cause side effects. Not everyone experiences side effects, and when they do occur, they are often mild and temporary. The most common side effects include:
- Dry mouth and increased thirst
- Insomnia or trouble sleeping
- Headache and dizziness
- Nausea and constipation
- Increased sweating
- Anxiety and restlessness
Dry mouth is one of the most frequently reported side effects and can often be managed by drinking plenty of water, chewing sugarless gum, or using oral moisturizing products. Insomnia is another common side effect, particularly when Bupropion is taken later in the day. Taking the last dose earlier in the evening or switching to the extended-release formulation taken in the morning can help alleviate this problem. Some patients also experience a slight increase in blood pressure, so regular monitoring is recommended for patients with hypertension.
Tremor, blurred vision, and changes in appetite may also occur. Bupropion is notable for not causing the weight gain commonly associated with other antidepressants. In fact, some patients experience modest weight loss, which can be either a welcome benefit or a concern, depending on the individual. Most side effects are most pronounced during the first one to two weeks of treatment and tend to diminish as the body adjusts to the medication. If side effects persist or become bothersome, patients should consult their healthcare provider. Dose adjustments, changes in formulation, or switching to a different medication may be options. Patients should never abruptly stop taking Bupropion without medical supervision, as this can lead to withdrawal symptoms such as irritability, anxiety, and sleep disturbances.
Serious side effects
Bupropion carries a risk of more serious side effects, although these are rare. The most significant concern is an increased risk of seizures. The risk of seizures is dose-dependent and is higher at doses above 450 mg per day. Patients with certain medical conditions, such as eating disorders (anorexia or bulimia), a history of seizures, or head trauma, are at higher risk. Because of this risk, Bupropion is contraindicated in patients with these conditions. Strict adherence to the prescribed dose is essential to minimize seizure risk. Other serious side effects include allergic reactions such as rash, hives, itching, difficulty breathing, and swelling of the face, lips, tongue, or throat. Any signs of an allergic reaction require immediate medical attention. Bupropion may also cause liver toxicity, although this is extremely rare. Symptoms of liver problems include yellowing of the skin or eyes, dark urine, abdominal pain, and unexplained fatigue.
Bupropion can increase the risk of suicidal thoughts and behaviors, particularly in children, adolescents, and young adults during the initial stages of treatment. The FDA requires a boxed warning, the most serious type of warning, for all antidepressants regarding this risk. Patients starting Bupropion should be closely monitored for worsening depression, unusual changes in behavior, or suicidal ideation. Family members and caregivers should also be alert to these signs. Bupropion may also trigger manic episodes in patients with bipolar disorder. It is important that healthcare providers screen patients for a history of bipolar disorder before prescribing Bupropion. Also, Bupropion can cause angle-closure glaucoma in patients with certain eye anatomy. This rare but serious condition requires immediate treatment to prevent vision loss.
Precautions and contraindications
Bupropion is not suitable for everyone. There are several conditions and situations in which Bupropion should not be used or should be used with caution. Bupropion is contraindicated in patients with a current or past diagnosis of bulimia or anorexia nervosa due to the increased risk of seizures. It is also contraindicated in patients with a seizure disorder or a history of seizures. Patients who are abruptly discontinuing alcohol, benzodiazepines, or other sedatives may also be at increased risk of seizures and should not take Bupropion. Bupropion is also contraindicated in patients who have taken a monoamine oxidase inhibitor (MAOI) within the past 14 days, as the combination can cause a dangerous increase in blood pressure. Taking Bupropion with other medications that contain Bupropion, such as some weight loss products, should be avoided to prevent excessive dosing.
Caution is required when prescribing Bupropion to patients with liver or kidney disease, as the medication is metabolized in the liver and excreted through the kidneys. Dose adjustments may be necessary for patients with impaired hepatic or renal function. Patients with a history of hypertension, particularly those with poorly controlled blood pressure, should be monitored closely. Bupropion can cause a slight increase in blood pressure in some individuals. Patients with diabetes, glaucoma, or a history of head trauma should also use Bupropion with caution. Bupropion is not recommended for use in children under 18 years of age for the treatment of depression, although it may be used off-label in some cases under specialist supervision. Pregnant women should only take Bupropion if the potential benefit justifies the potential risk to the fetus, and breastfeeding mothers should consult their healthcare provider, as Bupropion passes into breast milk.
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Drug interactions
Bupropion can interact with many medications. One of the most significant interactions is with monoamine oxidase inhibitors (MAOIs), which can cause a hypertensive crisis. Other antidepressants can interact with Bupropion, potentially increasing seizure risk or causing serotonin syndrome, a rare but serious condition.
Bupropion is metabolized by CYP2B6 in the liver. Inhibitors like clopidogrel increase Bupropion levels, while inducers like carbamazepine decrease them. Bupropion inhibits CYP2D6, raising levels of drugs metabolized by this enzyme, including beta-blockers, antiarrhythmics, antipsychotics, and some antidepressants. Dose adjustments of these medications may be necessary.
Alcohol can increase the risk of seizures and other side effects when taken with Bupropion. Patients are generally advised to limit or avoid alcohol consumption while taking Bupropion. The combination of alcohol and Bupropion can also worsen side effects such as dizziness, drowsiness, and impaired judgment. Nicotine replacement therapies, such as nicotine patches or gum, can be used safely with Bupropion, but this combination may increase the risk of high blood pressure in some patients. Blood pressure should be monitored if these therapies are combined. Other medications that lower the seizure threshold, such as antipsychotics, certain antibiotics, theophylline, and systemic corticosteroids, may increase the risk of seizures when taken with Bupropion. Patients taking these medications should be closely monitored. It is also important to note that grapefruit juice may interact with Bupropion, potentially affecting its absorption and metabolism. Patients should discuss dietary considerations with their healthcare provider.
Who should not take bupropion
Bupropion is not appropriate for everyone, and certain individuals should avoid this medication entirely. As previously mentioned, patients with seizure disorders, including epilepsy, should not take Bupropion because it lowers the seizure threshold. This includes individuals who have had a seizure from any cause, including head trauma or stroke. Patients with eating disorders such as anorexia nervosa or bulimia nervosa are at higher risk of seizures when taking Bupropion and should not use this medication. Individuals who are undergoing abrupt discontinuation of alcohol or sedatives such as benzodiazepines are also at increased seizure risk and should avoid Bupropion. Patients who have taken a monoamine oxidase inhibitor (MAOI) within the last two weeks should not start Bupropion due to the risk of a hypertensive crisis.
Patients with a known hypersensitivity or allergy to Bupropion or any of its inactive ingredients should not take the medication. Individuals with certain types of glaucoma, particularly angle-closure glaucoma, may experience worsening of their condition. Patients with severe liver cirrhosis or severe kidney impairment may require dose adjustments or may not be able to take Bupropion at all. Pregnant women, particularly those in the first trimester, should discuss the risks and benefits carefully with their healthcare provider, as some studies have shown an increased risk of certain birth defects. However, untreated depression during pregnancy also carries significant risks. Breastfeeding mothers should also weigh the risks and benefits, as Bupropion passes into breast milk in small amounts. Children and adolescents under 18 years of age should be evaluated carefully before being prescribed Bupropion, as it has not been studied in this age group for depression treatment.
Bupropion vs. Other antidepressants
Bupropion differs from other commonly prescribed antidepressants in several important ways. Unlike selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac), sertraline (Zoloft), and escitalopram (Lexapro), Bupropion does not affect serotonin levels. This means it has a different side effect profile and may be better tolerated by some patients. One of the main advantages of Bupropion over SSRIs is its minimal impact on sexual function. SSRIs are known to cause decreased libido, delayed orgasm, and erectile dysfunction in a significant percentage of patients. Bupropion, by contrast, rarely causes sexual problems and may actually enhance sexual function in some individuals. Another advantage is that Bupropion is less likely to cause weight gain. In fact, many patients experience modest weight loss while taking Bupropion. SSRIs and SNRIs are more frequently associated with weight gain, particularly with long-term use.
SNRIs such as venlafaxine and duloxetine affect both serotonin and norepinephrine. Bupropion’s additional effect on dopamine provides a distinct profile, making it particularly effective for depression with low energy, lack of motivation, and concentration difficulties. Bupropion is less likely to cause sedation and fatigue. However, it is not as effective for anxiety disorders and may worsen anxiety. SSRIs and SNRIs are preferred for co-occurring anxiety and depression, while Bupropion is reserved for patients without significant anxiety or who need its specific benefits.
Bupropion and weight management
One of the distinctive features of Bupropion is its effect on body weight. While many antidepressants are associated with weight gain, Bupropion is associated with modest weight loss in many patients. This is thought to be related to its effects on dopamine and norepinephrine, which can increase energy expenditure and reduce appetite. The average weight loss observed in clinical studies is modest, typically in the range of two to five pounds over the course of treatment. However, some patients lose more, and others may not experience any change. The weight loss effect is usually most pronounced in the first few months of treatment and may stabilize over time. This makes Bupropion an attractive option for patients who are concerned about weight gain or who have struggled with their weight on other antidepressants.
The weight loss properties of Bupropion have led to its use in combination with naltrexone for the treatment of obesity. This combination is sold under the brand name Contrave and is FDA-approved for chronic weight management in adults with obesity or overweight with at least one weight-related condition. Naltrexone is an opioid antagonist that works on the brain’s reward system to reduce food cravings. When combined with Bupropion, the two medications have a synergistic effect that promotes greater weight loss than either medication alone. Clinical trials have shown that patients taking this combination can achieve significant weight loss, particularly when combined with lifestyle modifications such as diet and exercise. However, Contrave carries the same seizure risk warning and contraindications as Bupropion, and careful patient selection is essential.
How to take bupropion safely
Taking Bupropion correctly is essential for both safety and effectiveness. Patients should follow their healthcare provider’s instructions carefully and read the medication guide provided with the prescription. Bupropion tablets should be swallowed whole and should not be crushed, chewed, or split, particularly the sustained-release and extended-release formulations. Crushing or chewing these tablets can cause the entire dose to be released at once, increasing the risk of side effects and seizures. Bupropion can be taken with or without food. If stomach upset occurs, taking it with food may help. The medication should be taken at the same time(s) each day to maintain consistent blood levels. For the once-daily extended-release formulation, taking it in the morning is recommended to minimize the risk of insomnia. For the twice-daily formulation, taking the second dose in the early afternoon, rather than in the evening, can also help prevent sleep difficulties.
If a dose is missed, patients should take it as soon as they remember, unless it is almost time for the next scheduled dose. In that case, the missed dose should be skipped and the regular dosing schedule resumed. Patients should not take two doses at once to make up for a missed dose. It is important to store Bupropion at room temperature, away from moisture, heat, and direct sunlight. The medication should be kept in its original container and out of reach of children and pets. Bupropion can cause dizziness or drowsiness in some patients, particularly at the beginning of treatment. Patients should not drive, operate heavy machinery, or engage in other activities requiring alertness until they know how the medication affects them. Alcohol should be avoided or consumed only in very limited amounts while taking Bupropion, as alcohol can increase the risk of seizures and other side effects. Regular follow-up appointments with a healthcare provider are important to monitor progress, manage side effects, and adjust the dose if needed.
Bupropion overdose: symptoms and treatment
Bupropion overdose requires immediate medical attention. Symptoms include seizures, hallucinations, loss of consciousness, rapid heart rate, high blood pressure, agitation, confusion, vomiting, and muscle rigidity. Seizures can occur with doses as low as 600 mg and are the most serious complication. Treatment occurs in a hospital setting and includes supportive care, activated charcoal, anticonvulsants, and cardiac monitoring. There is no specific antidote. Patients are monitored for 24 to 48 hours due to the risk of delayed seizures. Bupropion should be kept securely out of reach of individuals who might misuse it.
Frequently asked questions about bupropion
How long does it take for bupropion to work?
The onset of action of Bupropion varies depending on the condition being treated. For depression, most patients begin to notice some improvement in mood, energy, and motivation within two to four weeks of starting treatment. However, the full therapeutic effect may take six to eight weeks or longer. For smoking cessation, the medication works more quickly, with patients typically experiencing reduced cravings within the first week. It is important to be patient and consistent with taking the medication as prescribed. Some patients may not notice significant improvement for several weeks, but this does not mean the medication is not working. Abruptly stopping Bupropion before it has had time to take effect can lead to disappointment and a missed opportunity for treatment.
Can bupropion be taken with other antidepressants?
In some cases, Bupropion is used in combination with other antidepressants as part of an augmentation strategy. This is most commonly done when a patient has had an incomplete response to A SSRI or SNRI alone. Bupropion is added to the existing antidepressant to enhance its effectiveness. This approach is particularly useful for patients who have residual symptoms such as low energy, lack of motivation, or sexual dysfunction. The combination of Bupropion with A SSRI or SNRI is generally safe, but patients should be monitored for potential interactions and side effects, including an increased risk of serotonin syndrome. Combining Bupropion with other medications that lower the seizure threshold should be approached with caution. The decision to combine antidepressants should only be made by a qualified healthcare provider with experience in psychopharmacology.
Is bupropion addictive?
Bupropion is not considered addictive and has a low potential for abuse. Unlike stimulants or benzodiazepines, Bupropion does not produce an euphoric high or a sense of intoxication when taken as prescribed. However, some individuals may misuse Bupropion, particularly those with a history of substance abuse. Symptoms of Bupropion misuse may include taking higher doses than prescribed, crushing and snorting the tablets, or using the medication without a prescription. Misuse of Bupropion can lead to serious side effects, including seizures, psychosis, and cardiac problems. Patients with a history of substance abuse should discuss this with their healthcare provider before starting Bupropion. The medication should be used exactly as prescribed, and any concerns about dependence or misuse should be addressed with a healthcare professional.
Can i drink alcohol while taking bupropion?
It is generally recommended to avoid or limit alcohol consumption while taking Bupropion. Alcohol can lower the seizure threshold, increasing the risk of seizures, which is already a concern with Bupropion. The combination of alcohol and Bupropion can also worsen side effects such as dizziness, drowsiness, and impaired coordination. Also, alcohol can worsen depression and reduce the effectiveness of the medication. Patients who consume large amounts of alcohol should not stop drinking abruptly while taking Bupropion, as sudden alcohol withdrawal can also trigger seizures. The safest approach is to avoid alcohol entirely during treatment. If a patient chooses to drink, they should do so in very limited amounts and discuss the risks with their healthcare provider. The effects of Bupropion and alcohol can be unpredictable, and individual tolerance varies widely.
What happens if i stop taking bupropion suddenly?
Suddenly stopping Bupropion can lead to withdrawal symptoms, although these are generally less severe than with some other antidepressants. Withdrawal symptoms may include irritability, anxiety, agitation, insomnia, vivid dreams, headaches, and nausea. More severe withdrawal symptoms such as confusion or seizures are rare but possible, particularly at higher doses. To minimize the risk of withdrawal, Bupropion should be tapered gradually under the supervision of a healthcare provider. The tapering schedule depends on the dose, duration of treatment, and individual patient factors. In addition to withdrawal symptoms, stopping Bupropion suddenly can also lead to a relapse of the underlying condition, whether depression or smoking. Patients who experience bothersome symptoms after stopping Bupropion should contact their healthcare provider. It is also important to note that the risk of seizures may persist for several days after the last dose, particularly at higher doses.
Can children take bupropion?
Bupropion is not FDA-approved for the treatment of depression in children under 18. However, it may be prescribed off-label for ADHD or when other treatments have failed. The risk of suicidal thoughts is a particular concern in younger patients, so close monitoring by healthcare providers and family members is essential.
Is bupropion safe for older adults?
Older adults may be more sensitive to side effects and are more likely to have medical conditions that interact with Bupropion. Lower starting doses and slower adjustments are recommended. Bupropion may be a good option for elderly patients concerned about SSRI side effects like falls from dizziness or hyponatremia, but requires careful monitoring.
Can bupropion help with anxiety?
Bupropion is not a first-line treatment for anxiety disorders and may worsen anxiety in some patients, particularly during the first weeks. SSRIs and SNRIs are preferred for co-occurring anxiety and depression. However, improvement in overall mood may indirectly help with mild anxiety in some patients.