A 45-year-old man with a past medical history of obesity presents with a concern about his sexual performance. He has a history of depression which is well managed with fluoxetine. He states that since starting the medication, his sexual drive has increased, yet he is unable to achieve orgasm. As a result, he refuses to take the medication anymore. He has a past medical history of diabetes and notes that his home blood glucose readings have been higher lately. His temperature is 98.3°F (36.8°C), blood pressure is 127/82 mmHg, pulse is 88/min, respirations are 14/min, and oxygen saturation is 99% on room air. Physical exam reveals an obese man in no acute distress with a normal affect and non-focal neurologic exam. The physician agrees to change the patient’s antidepressant. Which of the following is the most appropriate treatment for this patient?
Electroconvulsive therapy
Mirtazapine
Bupropion
Phenelzine
Bupropion
This patient is presenting with anorgasmia in the setting of treatment with a selective serotonin reuptake inhibitor (SSRI). Given his obesity, worsening home blood glucose levels, and desire for improved sexual performance, bupropion is an appropriate medication.

Bupropion is an antidepressant that is not used first-line except in certain circumstances. Situations where bupropion is an appropriate agent for the management of depression include smoking cessation as it decreases smoking cravings. Bupropion is also weight neutral and is preferred in obese patients, patients who are gaining weight on other medications, and patients with poorly-managed diabetes. Finally, it does not have any sexual side effects in contrast to SSRIs. However, bupropion lowers the seizure threshold and should be avoided in patients at higher risk for seizures. Bupropion is sometimes given with other antidepressants for patients with persistent or refractory symptoms.

Patel et al. review bupropion. They note the effectiveness of bupropion in managing depression and note that it can be given with other agents. They recommend its use, in particular, for smoking cessation or patients who need a more weight-neutral treatment.

Incorrect Answers:
Answer B: Electroconvulsive therapy is a highly effective therapy for depression; however, it is generally used in cases of severe suicidality, malnutrition due to food refusal secondary to depressive disorder, or last line when other medications have failed. This patient is primarily experiencing sexual side-effects and has gained weight, making bupropion a more viable initial alternative.

Answer C: Escitalopram is merely a different SSRI that will lead to similar side effects. Thus, it would not be appropriate. Changing SSRIs is appropriate if the first SSRI does not work after an appropriate trial period of at least 4 weeks in the management of depression. Other changes when an SSRI fails to control symptoms include increasing the dose.

Answer D: Mirtazapine is an antidepressant that increases appetite and leads to weight gain and would further worsen this patient’s obesity. It is preferred in conditions such as anorexia nervosa given weight gain is preferable in this population.

Answer E: Phenelzine is a monoamine oxidase inhibitor and is usually used third-line (or later) in the management of depression given side-effects such as hypertensive crisis and the long washout period and interactions with other medications. Bupropion is a safer initial alternative.

Bullet Summary:
Patients with depression who experience sexual side effects or weight gain on SSRIs may be switched to bupropion.