Bupropion is an antidepressant, which inhibits reuptake of norepinephrine and dopamine. It is a relatively reliable antidepressant in terms of side effects and also is used in the treatment of nicotine deprivation (1, 2). Most frequent side effects are insomnia, dry mouth, and headache (3). Here we present a case who developed visual hallucinations during bupropion treatment. Case: F.Y: A 51 year old woman was admitted to the outpatient clinic with complaints of hump, horror, and seeing spider images. Visual hallucinations, anxiety, irritability, insomnia, and anhedonia were noted on psychiatric examination. Except for the visual hallucinations, there was no other perception abnormality nor other psychotic symptoms. History: she reported to a psychiatrist with complaints of joylessness, weakness, fatigue, and anhedonia. She was diagnosed with major depressive disorder and subsequently was put on bupropion 150mg/day. After a week, the dosage of bupropion was increased to 300mg/day. On the first day of the bupropion dose increase to 300 mg/day, spider images developed in both of her eyes and in the following days these images increasingly continued. The images lasted for days and scared the patient, ruined her sleep pattern, and increased her anxiety. The patient saw an ophthalmologist with these complaints and at the medical examination there was no evidence of an organic or pathological disorder. Her blood pressure was under control with treatment. The patient had been treated with escitalopram and duloxetine 6 years ago with a diagnosis of depressive disorder, but the patient specified that she had not had any visual complaints. There were not any relevant symptoms at that time and patient was not describing any clear stress factors. The family history was unremarkable. The patient did not have such complaints as dizziness, tinnitus, or paraesthesia and there was not any pathological finding at the neurological examination. Also there were no abnormal findings in the blood tests, urinalysis, and MR imaging. The Beck depression, Beck anxiety, and SCL-90 scales showed high levels of anxiety and moderate depression. After the assessment of all these data, suspicion was focused on the bupropion as the main cause of the spider images (visual hallucinations). The patient did not accept hospitalization, thus she was followed up periodically. First the dosage of bupropion was decreased to 150 mg and bupropion treatment was stopped completely in a few days. Alprazolam 0.5 mg/day treatment was started to decrease the patient's anxiety. Paroxetine 10 mg/ day was started and increased to 30 mg/day in two weeks. Following the discontinuation of the bupropion, the visual hallucinations disappeared in a few days. The patient came for controls monthly and at the end of the 6th month the symptoms of depression and anxiety had decreased considerably.
Comment: Bupropion has become a popular antidepressant in the treatment of depressive disorders in Turkey and is preferred frequently because of its relatively low incidence of side effects. Nevertheless every kind of side effects including psychotic symptoms that appear during treatment should be assessed carefully.
References:
1. Ascher JA, Cle JO, Colin JN, et al. Bupropion: A review of its mechanism of antideressant activity. J Clin Psychiatry 1995;56:395-401. Poster Presentations
2. Englisch S, Inta D, Eer A, Zink M (2010) Bupropion for depression in schizophrenia. Clin Neuropharmacol; 33(5): 257-259. Poster Presentations 3. Hurt RD, Sachs DPL, Glover ED, Offord KP, Johnston JA, Dale LC, et al. A comparison of sustained release bupropion and placebo. N Engl J Med 1997;337:1195-1202.