Bupropion-Induced Psychosis

Mr. A, a 79-year-old, widowed, retired Hispanic man with no history of psychiatric or substance abuse came to the emergency room after attempting suicide by slashing both of his wrists with a razor blade. On admission, his history and the results of a mental status examination were consistent with an initial episode of severe major depression. There was no evidence of delusions, hallucinations, or a thought, perceptual, or cognitive disturbance. Results of a physical examination, including an extensive hematological and metabolic screening, as well as an ECG and chest X-ray, revealed no significant abnormalities. His medical history was significant for the presence of osteoarthritis, gout, gastritis, and glaucoma, for which he took ibuprofen, sucralfate, and colchicine and used a betaxolol hydrochloride opthalmic solution. Bupropion treatment was started at a dose of 75 mg/day and titrated to a dose of 100 mg t.i.d. over the next 7 days. Despite a gradual improvement in mood, Mr. A began to exhibit some paranoid ideation on the fourth day of bupropion treatment. Mr. A’s paranoia increased over the next 3 days, and he began experiencing auditory hallucinations. His dose of bupropion was decreased to 25 mg/day. Haloperidol treatment was initiated at a dose of 2 mg/day and subsequently titrated to 5 mg/day over the next 5 days. During the following week, Mr. A’s psychotic symptoms decreased until they were entirely absent. Haloperidol treatment was discontinued, and his dose of bupropion was again titrated upward, this time to a final dose of 25 mg t.i.d. He did not experience a recurrence of either depressive or psychotic symptoms during the next 3 months of follow-up care.