Why Isn’t Bupropion the Most Frequently Prescribed Antidepressant?

Objective: Reviews of antidepressant medication efficacy suggest that all antidepressants are equally effective. Bupropion is less likely than other antidepressants to cause weight gain and sexual dysfunction, the 2 side effects that are of greatest concern to patients and that have the greatest impact on long-term compliance. If bupropion is as effective as other antidepressants, and it does not cause the side effects that are the most frequent causes of long-term noncompliance, then why isn’t it the most frequently prescribed antidepressant medication? To understand psychiatrists’ decision making at the time an antidepressant is chosen, we conducted the Rhode Island Factors Associated With Antidepressant Choice Survey (FAACS).

Method: For 1137 DSM-IV–diagnosed depressed patients initiated on an antidepressant, the treating psychiatrist completed a 43-item questionnaire listing factors that might have influenced the choice of medication. The questionnaire was filled out immediately after the antidepressant was prescribed to treat a depressive disorder. This study was conducted from August 2001 to February 2002.

Results: Because the reasons for choosing a medication to augment an existing regimen might be different from those used in monotherapy, augmentation trials were excluded from the analysis, leaving a sample of 965 patients. Bupropion was rarely prescribed when the presence of comorbid anxiety disorders or symptoms reflecting central nervous system activation influenced antidepressant selection. When the desire to avoid side effects, especially sexual dysfunction and weight gain, were the basis of selection, then bupropion was significantly more often prescribed than other antidepressants (p < .001).

Conclusions: Although there is little evidence that patient factors predict differential medication response, psychiatrists are strongly inclined to base antidepressant selection on clinical profiles and avoid prescribing bupropion for depressed patients with high anxiety. Possible reasons for the discrepancy between psychiatrists’ prescribing habits and the results of empirical study are discussed.