Choosing bupropion after SSRI sexual dysfunction (CASC)

Station instructions (candidate)

You have 7 minutes. Explore goals: mood recovery, sexual function, smoking, weight concerns. Explain that sertraline-related sexual dysfunction is common and treatable by strategy, not shame. Offer a collaborative plan that may include switching to or adding bupropion after screening for seizure risk factors, with a clear oral dose plan and early review. Contrast honestly with mirtazapine (helpful for sleep/appetite; sedation and weight gain trade-offs). Do not claim zero seizure risk. Do not start venlafaxine+mirtazapine tonight as casual "rocket fuel." Do not dismiss online fears.[1][3][4][6][7]

Marking domains

Rapport and agenda setting; accurate sexual side-effect validation; bipolar screen mentioned; bupropion mechanism in plain language; seizure risk explained without terror or denial; smoking dual benefit opportunity; mirtazapine contrast; dose and follow-up plan; shared decision and right to decline; safety netting for activation/suicidality.[1][2][4][5][8]

Model communication map

1. Open: thank them; name priorities (mood, sex, smoking, not gaining weight).[8]
2. Validate sexual SE: many people on serotonergic antidepressants get delayed orgasm or lower desire — it is a drug effect we take seriously, not a personal failing.[3]
3. Options in plain language: keep/adjust sertraline; switch to bupropion; or add bupropion if mood partly better — trials support bupropion after SSRI incomplete response as switch or augment.[1][2]
4. What bupropion is: works more on noradrenaline and dopamine systems than serotonin reuptake; often kinder to sexual function in comparative data.[3]
5. Seizure honesty: seizures are uncommon at usual modern doses but risk rises with certain histories (eating disorders, alcohol withdrawal, prior seizures, very high doses) — we screen, we do not pretend risk is zero.[4]
6. Smoking: same medicine class has controlled-trial evidence for helping people stop smoking with support; we can pair with behavioural help or nicotine replacement if wanted.[5]
7. Mirtazapine contrast: excellent when sleep and appetite are the main problems because of different receptor effects, but often increases sleepiness and weight — not your preferred trade-off today.[6]
8. Plan if agreeing: example bupropion XL 150 mg daily then 300 mg if tolerated; early phone/clinic review; crisis contacts; do not stack random extra antidepressants tonight (combinations are for selected later steps, not automatic).[1][7][8]
9. If declining medicine change: honour choice; sex-focused strategies and therapy still available; door open.[8]
10. Close: written plan; what to do if agitation or suicidal thoughts increase after change.[8]

Risk and safety notes for examiner

Candidate should not invent MAOI combinations, minimise eating-disorder seizure risk, promise bupropion never causes seizures, or start dual SNRI+mirtazapine without TRD framing.[4][7]