Bupropion

• Common (>10%):

  • Dry mouth (~17–24%)
  • Insomnia (~20–45%, dose-dependent — solvable by AM-only XL)
  • Headache (up to ~34%, including migraine-type)
  • Nausea (~13–22%)
  • Anxiety/agitation (~7–12%, mainly first 1–2 weeks)
  • Constipation
  • Tremor (up to ~21%)
  • Reduced appetite + modest weight loss
  • Sweating (excessive — diaphoresis)
  • Dizziness (up to ~22%)

• Less common (1–10%):

  • Tinnitus (case-reportable; usually reversible with dose reduction or discontinuation)
  • Tachycardia + mild BP elevation (clinically relevant if pre-existing hypertension)
  • Constipation, blurred vision
  • Rash (warrants attention — see rare/serious below)
  • Sexual dysfunction (rare — usually IMPROVES sexual function unlike SSRIs)

• Rare-serious (<1% but worth knowing):

  • Seizures (PRIMARY CONCERN — see dedicated section below): Dose-dependent. ~0.1% at SR ≤300 mg/day; ~0.4% at IR 300–450 mg/day; ~10× jump between 450 and 600 mg/day. Almost all seizures occur in patients with risk factors.
  • Hypertensive crisis if combined with MAOI (selegiline >10 mg, phenelzine, tranylcypromine) — contraindicated
  • Psychosis in predisposed individuals — case reports, especially in those with cocaine/stimulant abuse history (sensitized DA system + bupropion DA push)
  • Serum sickness-like reaction — rare hypersensitivity, watch first 4 weeks
  • Stevens-Johnson syndrome / TEN — extremely rare but reported; stop immediately for any rash
  • Suicidal ideation (FDA black-box warning for all antidepressants in <25yo) — Dylan is 20, so this warning applies; the actual signal is small but real
  • Mania induction in undiagnosed bipolar patients

• Specific watch periods:

  • First 4 weeks: Peak anxiety, insomnia, GI complaints; rash watch (SJS, serum sickness)
  • First 8 weeks: Most seizures occur during initial titration — start low, go slow
  • First 4–6 weeks: Suicidal ideation watch (especially <25yo)

THE SEIZURE-THRESHOLD QUESTION FOR DYLAN

This is the section that matters most.

Background incidence (general population):

• Bupropion XL ≤300 mg/day: ~0.1% seizure incidence (1 per 1000)
• Bupropion IR 300–450 mg/day: ~0.4% (1 per 250)
• Bupropion >450 mg/day: ~10-fold higher than 450 mg
• For comparison: General population baseline epilepsy lifetime risk is ~3%; annual incidence in healthy adults ~0.04%

FDA labeling for Wellbutrin XL contraindicates use in patients with:

1. Seizure disorder (active or history)
2. Anorexia nervosa or bulimia (current or past) — Dylan: clear, no eating-disorder history
3. Abrupt benzodiazepine/alcohol withdrawal — Dylan: clear, zero alcohol baseline
4. "Head trauma or central nervous system pathology" — THE OPEN QUESTION FOR DYLAN

The MMA subconcussive question — honest assessment:

Dylan trains 10+ hr/week MMA: 2hr lifting/conditioning Mon–Thu, 1.5hr Saturday hard sparring, daily light sparring with subconcussive impact. He has no diagnosed concussions and wears a custom mouthguard. The honest pharmacology/neurology read:

1. The FDA "head trauma" contraindication is written for moderate-to-severe TBI, post-concussion patients with cortical scarring, penetrating injury, etc. — not for athletes with no diagnosed concussion. There is no published threshold defining "head trauma" in the bupropion label.

2. Subconcussive impacts measurably alter brain physiology — cumulative subconcussive exposure correlates with white matter changes (DTI) and biomarker shifts (NfL, GFAP, tau) over years, even without symptomatic concussion. The mechanism by which this would lower seizure threshold is plausible but not directly demonstrated.

3. TBI literature consensus: For mild TBI patients (which is the closest published parallel to subconcussive exposure), bupropion XL is considered cautiously usable — the seizure-risk increase appears restricted mostly to IR formulations. SSRIs are the conventional first-line for post-TBI depression specifically because of this caution.

4. The kicker: Dylan trains daily. A seizure during sparring would be catastrophic — both for him and for whoever is on the other end of it. Even a 0.1% annual seizure risk applied to a daily-impact athlete is a different ethical calculus than the same number for a sedentary office worker.

Honest verdict on the seizure question: The risk at 150 mg XL is small in absolute terms (~1 in 1000/year), and likely not meaningfully elevated above general population for an athlete with no diagnosed concussion. But it is non-zero, the FDA label hedges this case, and the consequences of a seizure during training are uniquely high. This is not a "definitely safe" decision — it's a "small risk that requires the prescriber to know about MMA training, agree it's acceptable, and you to be vigilant for any prodromal symptoms (myoclonus, déjà vu spells, brief LOC, focal motor twitches)."

My recommendation: Do not skip this risk by self-prescribing or under-disclosing to a telehealth provider. Disclose the MMA training. If the prescriber is uncomfortable, they're correctly cautious — find a sports-psych-aware prescriber. 150 mg XL is the absolute ceiling regardless of what the prescriber suggests. Skip 300 mg unless the floor of evidence shifts.