A 20-year-old woman comes to the office due to "feeling low" for the past 2 months. The patient says, "All I do is sleep and cry. I lost my job last week and now I have to move in with my parents. I feel like a failure." She is upset that she has gained weight and says, "My junk food cravings have gotten worse, but I've been too tired to go to the gym to make up for it." The patient does not use alcohol or illicit drugs and takes no medications. Medical history is insignificant. Temperature is 36.7 C (98.1 F), blood pressure is 106/69 mm Hg, pulse is 90/min, and respirations are 16/min. On physical examination, the thyroid is normal to palpation. The lungs are clear to auscultation and heart sounds are normal. The abdomen is soft and nontender. Laboratory results are as follows:
| Complete blood count | |
| Hemoglobin | 14 g/dL |
| Platelets | 200,000/mm3 |
| Leukocytes | 8,000/mm3 |
| Serum chemistry | |
| Sodium | 136 mEq/L |
| Potassium | 3.2 mEq/L |
| Chloride | 93 mEq/L |
| Bicarbonate | 31 mEq/L |
| Creatinine | 0.8 mg/dL |
| Endocrine | |
| TSH | 3.4 µU/mL |
Which of the following medications would be contraindicated in this patient?
Although this patient's chief concern is depression, her presentation is highly suggestive of comorbid bulimia nervosa (BN). Her laboratory findings of hypokalemic, hypochloremic metabolic alkalosis are a classic sign of self-induced vomiting, one of the most common methods of purging in BN. In addition, the patient appears to be describing a difficult relationship with food, a possible history of compensatory exercise behaviors (eg, previously going to the gym to make up for the food cravings), and self-critical thoughts influenced by her body image.
Antidepressant selection in this patient should take the effects on seizure threshold into account due to the electrolyte abnormalities associated with purging behaviors. The norepinephrine dopamine reuptake inhibitor bupropion may lower seizure threshold. Therefore, it is contraindicated in patients with BN, anorexia nervosa, or epilepsy. When not contraindicated, bupropion offers unique benefits as an antidepressant because it is not associated with weight gain or sexual dysfunction.
(Choices B, C, and F) The selective serotonin reuptake inhibitors citalopram and fluoxetine and the serotonin norepinephrine reuptake inhibitor venlafaxine are not contraindicated in this patient. Fluoxetine is considered the drug of choice for BN.
(Choice D) Although mirtazapine may not be optimal due its potential to stimulate appetite, there are no absolute contraindications to its use in this patient. Like bupropion, the alpha-2 adrenergic antagonist antidepressant mirtazapine does not cause sexual dysfunction.
(Choice E) Trazodone is a mild serotonin reuptake inhibitor with additional activity at the 5-HT2A and 5-HT2C receptors. It is used for insomnia in the setting of depression. Although trazodone would not be optimal due to side effects of sedation and orthostatic hypotension, there are no contraindications for this medication in this patient's history.
Educational objective:
Bupropion is associated with an increased risk of seizures. It is contraindicated in patients with seizure disorders, anorexia nervosa, or bulimia nervosa.