Wellbutrin vs Benzodiazepines for Anxiety: A Psychiatric Provider's Clinical Comparison

Three benzodiazepines over two years. Xanax helped for a few hours, then wore off. Ativan made her too sedated to work. Klonopin had her sleeping 12 hours a night.

"I can't live like this. But without them, I can't function."

Sarah's dilemma is remarkably common. Research shows 44% of regular benzodiazepine users develop significant dependence after just four weeks (Pollack et al., 2003). Yet when her previous psychiatrist suggested Wellbutrin, she refused. "I have anxiety, not depression. Won't it make me more anxious?"

This confusion makes sense. Most providers never explain the fundamental difference between these medications - which is why patients end up on the wrong one for months, or worse, dependent on benzodiazepines they cannot safely stop.

Wellbutrin and benzodiazepines represent completely opposite approaches to anxiety. One activates, one sedates. One takes weeks, one works in minutes. One addresses the root problem, one masks symptoms. Understanding this difference is often the key to getting unstuck.

The Critical Difference Most Providers Don't Explain

Here's what matters: Wellbutrin (bupropion) is activating. Benzodiazepines are calming.

This isn't a minor detail. It's the entire story.

If your anxiety comes from too little energy, motivation, and focus - what feels like everything requires enormous effort, your brain won't cooperate, you're overwhelmed by tasks that should be manageable - Wellbutrin can help by increasing dopamine and norepinephrine. More activation, more drive, better executive function.

If your anxiety comes from too much nervous system arousal - racing heart, sweating, panic attacks, physical symptoms of fear - benzodiazepines can help by enhancing GABA, your brain's main calming neurotransmitter. Immediate sedation, reduced arousal, physical calm.

The problem? Most people with anxiety have been told they need calm, when what they actually need is focus and energy to manage the overwhelm.

Let me show you the difference.

What Wellbutrin Actually Does (And Doesn't)

Mechanism of Action

Wellbutrin (bupropion) is an NDRI - norepinephrine-dopamine reuptake inhibitor. It increases two neurotransmitters:

• Norepinephrine: Alertness, attention, motivation
• Dopamine: Reward, drive, focus

It does NOT affect serotonin (unlike SSRIs), which is why it doesn't cause the sexual side effects that drive 30-40% of SSRI discontinuations.

FDA Approval Status

Here's what surprises most patients: Wellbutrin is not FDA-approved for any anxiety disorder.

It's approved for:

• Major depressive disorder
• Smoking cessation
• Seasonal affective disorder

When I prescribe it for anxiety, it's off-label. This doesn't mean it doesn't work - many effective psychiatric medications are used off-label. It means the clinical trial data for anxiety is limited.

The Evidence for Anxiety

The research on bupropion for anxiety is mixed:

For generalized anxiety disorder (GAD): Weak evidence. Some studies show modest benefit, others show it can worsen anxiety. Not recommended as first-line.

For panic disorder: Limited data. Most clinicians avoid it due to activation concerns.

For social anxiety disorder: No convincing evidence.

For anxious depression: Strong evidence. Research suggests that for patients with depression and co-occurring anxiety, bupropion may be as effective as SSRIs, often with better tolerability and fewer sexual side effects.

Translation: If you have depression with anxiety (not pure anxiety), bupropion is a reasonable option. If you have primary anxiety without depression, it's rarely first-line.

Timeline and Expectations

Week 1-2: Some patients feel MORE anxious. The norepinephrine increase can cause:

• Increased nervousness or jitteriness
• Initial insomnia
• Restlessness
• Activation that feels uncomfortable

Week 3-4: Symptoms often stabilize as your nervous system adjusts to higher dopamine and norepinephrine levels.

Week 6-8: If bupropion is going to help, this is when you'll notice:

• Better ability to manage tasks (reduced "overwhelm anxiety")
• Improved motivation and follow-through
• Less fatigue driving anxiety
• Clearer thinking under stress

If by week 8 your anxiety is worse or unchanged, bupropion probably isn't the right medication for your anxiety type.

Who Benefits From Wellbutrin for Anxiety

In my practice, patients who respond well to bupropion for anxiety typically have these characteristics:

1. Depression is the primary problem, anxiety is secondary

• Low mood, anhedonia (inability to feel pleasure), low motivation
• Anxiety manifests as worry about not getting things done, feeling stuck, fear of failure
• Energy and motivation improvement reduces the anxiety

2. ADHD symptoms are driving the anxiety (more on this below)

• Executive dysfunction creates overwhelm
• Procrastination creates deadline panic
• Poor time management creates constant stress
• Bupropion improves focus and reduces ADHD-driven anxiety

3. SSRI sexual side effects are intolerable

• Previous SSRI helped anxiety but caused sexual dysfunction
• Switched to bupropion, maintained anxiety relief without sexual side effects
• This is one of the most common reasons I use bupropion

4. Fatigue and anxiety are both problems

• "I'm tired but wired"
• SSRIs made them too sedated
• Bupropion provides activation without worsening anxiety (once adjusted)

Dosing and Titration

Starting dose:

• Wellbutrin XL 150mg once daily (extended-release, taken in morning)
• Start low to minimize activation side effects

Typical therapeutic dose:

• 300mg daily (most common effective dose for depression and anxiety)
• Some patients need 450mg (maximum dose)

Titration schedule:

• Start 150mg × 4 weeks
• If tolerating well but partial response: Increase to 300mg
• Reassess at 8 weeks total

Maximum dose: 450mg daily (seizure risk increases above this dose)

Side Effects and Risks

Common side effects (10-25% of patients):

• Insomnia (take early in day)
• Dry mouth
• Headache
• Nausea
• Weight loss (5-10 pounds average)
• Increased anxiety initially

Serious risks:

• Seizure risk: 0.1% at 300mg, 0.4% at 450mg (dose-dependent)
• Contraindicated in:
• History of seizures or seizure disorder
• Current or prior bulimia or anorexia (increased seizure risk)
• Abrupt discontinuation of alcohol or benzodiazepines (lowers seizure threshold)

Black box warning: Increased suicidal thoughts in young adults (under 25) in first 1-2 months - applies to all antidepressants, not specific to bupropion.

The ADHD-Anxiety Connection Nobody Talks About

This is critical and frequently missed: Many people diagnosed with "generalized anxiety disorder" actually have undiagnosed ADHD.

Here's how it looks in my office:

Patient presentation: "I'm anxious all the time. I can't stop worrying about everything I need to do. My mind races. I can't focus because I'm so stressed."

What's actually happening:

• Executive dysfunction makes task initiation difficult
• Working memory deficits lead to forgetting things, which creates anxiety about forgetting more things
• Time blindness creates deadline panic
• Poor organization creates constant overwhelm
• The anxiety is secondary to ADHD, not primary

Why this matters for medication choice:

If you give benzodiazepines to someone with ADHD-driven anxiety:

• They feel temporarily calm
• But they still can't focus, organize, or execute tasks
• The overwhelm returns as soon as the benzo wears off
• They become dependent on benzos to manage anxiety that has an ADHD root cause

If you address the ADHD (with bupropion, stimulants, or strattera):

• Executive function improves
• Tasks become manageable
• The overwhelm-driven anxiety reduces naturally
• No benzodiazepines needed

How to Tell If Your Anxiety Is Actually ADHD

Ask yourself these questions:

1. Is your anxiety worse when you're trying to start or complete tasks?

• If yes: Suggests executive dysfunction anxiety

2. Do you constantly worry about forgetting things or missing deadlines?

• If yes: Suggests working memory-driven anxiety

3. Does your anxiety improve when you're doing engaging, interesting activities?

• If yes: Suggests ADHD (anxiety disappears when dopamine is activated)

4. Do you feel overwhelmed by tasks that others handle easily?

• If yes: Suggests executive dysfunction

5. Have stimulants (like caffeine) ever made you feel MORE calm and focused?

• If yes: Strong indicator of ADHD

If you answered yes to 3+ questions, the anxiety might be secondary to ADHD - and treating the ADHD treats the anxiety.

In these cases, bupropion can be remarkably effective because it provides:

• Improved focus and attention
• Better task initiation
• Enhanced motivation
• Reduced executive dysfunction

And as those improve, the overwhelm-driven anxiety naturally decreases.

What Benzodiazepines Actually Do

Mechanism of Action

Benzodiazepines (Xanax, Ativan, Klonopin, Valium) are GABA-A receptor positive allosteric modulators. Translation:

They enhance GABA (gamma-aminobutyric acid), your brain's main inhibitory neurotransmitter. GABA slows down neural activity. More GABA = more neuronal calming = reduced anxiety, reduced muscle tension, sedation.

How They Work vs. How Wellbutrin Works

• Drug Class: GABA-PAM (enhances GABA) — NDRI (blocks reuptake of dopamine/norepinephrine)
• Mechanism: Increases inhibitory (calming) neurotransmission — Increases excitatory (activating) neurotransmission
• Effect: Sedating, calming, muscle relaxation — Activating, energizing, focus-enhancing
• Onset: 30-60 minutes (immediate relief) — 4-6 weeks (gradual improvement)
• Duration of Action: 4-24 hours (depends on specific benzo) — All day (once-daily dosing)
• Dependency Risk: High (44% after >4 weeks regular use) — Low (not habit-forming)
• Withdrawal: Can be severe (seizures, psychosis if stopped abruptly) — Minimal (can discontinue without taper at lower doses)
• FDA Approval for Anxiety: Yes (multiple anxiety disorders) — No (off-label use)
• Best Use Case: Acute panic, short-term crisis management, bridge therapy — Anxious depression, ADHD-driven anxiety, SSRI intolerance

The Evidence for Benzodiazepines in Anxiety

Benzodiazepines are FDA-approved and have strong evidence for:

Generalized Anxiety Disorder (GAD):

• 60-70% response rate
• Effective within 30-60 minutes
• Problem: Tolerance develops (need higher doses over time)

Panic Disorder:

• 62-74% response rate (NNT = 4, meaning 4 patients need treatment for 1 to benefit beyond placebo)
• Immediate relief of panic attacks
• Problem: Patients become dependent, panic returns when medication wears off

Social Anxiety Disorder:

• Effective for acute situations (taking Ativan before public speaking)
• Not recommended for daily use
• Better options: SSRIs, CBT

Why They Work So Well (And Why That's a Problem)

The immediate relief is what makes benzodiazepines so effective - and so risky.

When you have a panic attack and take Xanax:

• Within 20-30 minutes: Heart rate slows, breathing calms, terror subsides
• Your brain learns: "Xanax = safety"
• Next time anxiety rises: Your brain wants Xanax
• Over time: You can't tolerate anxiety without medication

This is psychological dependence. But there's also physical dependence.

Dependency and Withdrawal: The Data

Physical dependence timeline:

• 2-4 weeks regular use: Mild dependence developing
• 4-8 weeks regular use: Moderate dependence likely

• >3 months regular use: 44% develop significant dependence

What "dependence" means:

• Tolerance: Need higher doses for same effect
• Withdrawal symptoms if you miss a dose or try to stop
• Rebound anxiety (anxiety worse than baseline when medication wears off)

Withdrawal syndrome:

If you stop benzodiazepines abruptly after regular use, you can experience:

• Severe rebound anxiety
• Insomnia
• Tremor
• Sweating
• Seizures (in severe cases)
• Psychosis (rare but documented)
• Protracted withdrawal: 10-25% experience symptoms lasting months or years

Tapering timeline:

• Short-term use (<1 month): Can stop over 1-2 weeks
• Medium-term use (3-6 months): Taper over 4-8 weeks
• Long-term use (>6 months): Taper over 8-16 weeks (or longer for high doses)

The 4x opioid risk:

If you're prescribed benzodiazepines AND opioids (pain medication), overdose risk increases 4-fold. This is why most providers now avoid co-prescribing.

When Benzodiazepines Are Appropriate

Despite the risks, there are legitimate uses:

1. Acute panic attacks (short-term, as-needed use)

• Take during panic attack for immediate relief
• Maximum 1-2 times per week
• Not daily use
• Often paired with CBT for panic disorder

2. Bridge therapy during antidepressant startup

• SSRIs/SNRIs take 4-8 weeks to work
• Benzodiazepines provide relief during that window
• Typical duration: 2-4 weeks, then taper off as SSRI takes effect
• This is one of the most appropriate uses

3. Situational anxiety (rare, predictable triggers)

• Flying phobia: Take Ativan before flight
• Medical procedures: Take Valium before MRI
• Maximum a few times per year
• Not for ongoing daily anxiety

4. Severe insomnia (very short-term)

• When insomnia is severe and other options have failed
• Maximum 1-2 weeks
• Transition to non-benzo sleep aids

Common Benzodiazepines: Half-Life Matters

• Xanax (alprazolam): 6-12 hours — Short-acting, fast relief — High abuse potential, quick tolerance
• Ativan (lorazepam): 10-20 hours — Medium-acting — Commonly used for panic, procedures
• Klonopin (clonazepam): 18-50 hours — Long-acting — More "stable" feeling, easier to taper
• Valium (diazepam): 20-100 hours — Very long-acting — Used for alcohol withdrawal, muscle spasm

Half-life significance:

• Shorter half-life = faster relief, faster withdrawal between doses (more rebound anxiety)
• Longer half-life = slower onset, more stable blood levels, easier to taper

The "Neither Is First-Line" Truth

Here's what I tell every patient considering either medication:

For most anxiety disorders, neither Wellbutrin nor benzodiazepines are first-line treatment.

First-line treatment is typically:

1. SSRIs or SNRIs (Lexapro, Zoloft, Prozac, Effexor)

• Strong evidence for most anxiety disorders
• Well-tolerated (though sexual side effects are common)
• Not habit-forming
• Take 4-8 weeks to work

2. Cognitive Behavioral Therapy (CBT)

• Equal efficacy to SSRIs for many anxiety disorders
• No side effects
• Skills last beyond treatment
• Often combined with medication

When do I use Wellbutrin for anxiety?

• When SSRIs caused sexual side effects
• When depression and anxiety coexist (anxious depression)
• When ADHD symptoms are driving the anxiety
• When fatigue and low motivation are major components

When do I use benzodiazepines for anxiety?

• Bridge therapy while SSRI takes effect (2-4 weeks max)
• Acute panic attacks (as-needed, not daily)
• Severe situational anxiety (flying, procedures, rare events)
• Never as first-line, ongoing daily treatment

The "Bridge Strategy": Using Both Together

One approach I use frequently: Start Wellbutrin, use benzodiazepines temporarily to manage activation.

Here's why this can work:

Week 1-2 of Wellbutrin:

• Patient experiences activation, jitteriness, initial anxiety increase
• This is expected but uncomfortable
• Many patients stop Wellbutrin because they can't tolerate this phase

Bridge solution:

• Prescribe low-dose Ativan or Klonopin for the first 2-3 weeks only
• "Take as needed when activation feels intolerable"
• Reassure: "This is temporary. Most patients adjust by week 3-4"
• Begin tapering benzodiazepine at week 3
• Discontinue by week 4-6

Why this works:

• Patients can tolerate Wellbutrin startup
• Wellbutrin has time to reach therapeutic effect
• Benzodiazepine use is short-term (minimal dependence risk)
• By week 6-8, Wellbutrin is working and benzo is discontinued

Critical requirement for this strategy:

• Patient must understand benzos are temporary
• Clear taper schedule discussed upfront
• Weekly check-ins to ensure compliance with taper
• History of substance use disorder may be a contraindication

What Medical Investigation Should Happen First

Before prescribing either Wellbutrin or benzodiazepines, I order comprehensive labs. Here's why:

Conditions that mimic or worsen anxiety:

1. Hyperthyroidism

• Symptoms: Racing heart, sweating, tremor, anxiety, weight loss
• Labs: TSH, Free T4, Free T3
• If TSH is low (<0.4) and Free T4/T3 are high: Hyperthyroidism is causing or worsening anxiety
• Treatment: Address thyroid first, then reassess anxiety

2. Iron deficiency

• Symptoms: Fatigue, restless legs, difficulty concentrating, anxiety
• Labs: Ferritin (must be >50 ng/mL, optimal >75 ng/mL)
• If ferritin is low: Anxiety may improve with iron repletion before medication needed

3. Vitamin D deficiency

• Associated with both depression and anxiety
• Labs: 25-OH Vitamin D (target 40-60 ng/mL)
• Supplementation often reduces anxiety symptoms

4. B12 deficiency

• Symptoms: Fatigue, brain fog, anxiety, depression
• Labs: B12 level (optimal >600 pg/mL), MMA and homocysteine if B12 is 200-400
• Treatment improves neurological and psychiatric symptoms

5. Cardiac arrhythmias

• Palpitations can feel identical to anxiety
• If patient reports "heart racing randomly," order: EKG, Holter monitor
• Rule out before attributing to anxiety

6. Hypoglycemia

• Low blood sugar causes anxiety symptoms
• Labs: Fasting glucose, HbA1c
• Dietary modifications may resolve anxiety

7. Perimenopause (women 35-55)

• Hormone fluctuations cause anxiety, panic, insomnia
• Labs: FSH, LH, Estradiol (day 3 of cycle if menstruating)
• Hormone optimization often more effective than psych meds

My standard anxiety workup:

• CBC (rule out anemia)
• CMP (kidney, liver, glucose, electrolytes)
• TSH, Free T4, Free T3 (thyroid)
• Ferritin (iron stores)
• Vitamin D
• B12
• HbA1c (blood sugar control)
• For women with menstrual changes: FSH, LH, Estradiol

If these labs reveal abnormalities, we optimize them first. Often, anxiety improves significantly before psychiatric medication is needed.

Real Scenarios: Which Medication for Which Patient?

Let me walk you through clinical decision-making with real (de-identified) cases:

Case 1: Anxious Depression with SSRI Side Effects

Presentation: 34-year-old woman, depression and anxiety for 2 years. Tried Lexapro 20mg - helped mood and anxiety but caused complete loss of libido and difficulty with orgasm. Stopped Lexapro, depression and anxiety returned.

Medical workup: TSH 2.1 (normal), Ferritin 48 (low-normal), Vitamin D 32 (low-normal). Otherwise healthy.

Clinical reasoning:

• Primary problem: Depression with anxiety (not pure anxiety disorder)
• SSRI was effective but sexually intolerable
• Wellbutrin reasonable alternative (doesn't affect serotonin, no sexual side effects)
• Optimize ferritin and vitamin D while starting medication

Treatment:

• Wellbutrin XL 150mg × 3 weeks, then increase to 300mg
• Ferrous sulfate 325mg daily (target ferritin >75)
• Vitamin D3 5,000 IU daily
• Warned about potential initial activation
• Ativan 0.5mg as-needed for first 3 weeks only (bridge strategy)

Outcome at 8 weeks:

• Depression much improved
• Anxiety reduced (not eliminated but manageable)
• No sexual side effects
• Ferritin now 68, Vitamin D 54
• Discontinued Ativan at week 4 without difficulty
• Staying on Wellbutrin 300mg

Why Wellbutrin worked: Anxious depression responds to bupropion, especially when SSRI side effects are intolerable.

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Case 2: ADHD-Driven Anxiety

Presentation: 28-year-old man, "constant anxiety about everything I need to do." Procrastinates until deadline, then panic-completes tasks. Feels overwhelmed by simple errands. Previous provider prescribed Xanax as-needed, which he took daily for 6 months. Still anxious, now also worried about Xanax dependence.

Medical workup: All labs normal. No thyroid, no anemia, no vitamin deficiencies.

Clinical reasoning:

• Anxiety is secondary to executive dysfunction (ADHD pattern)
• Benzodiazepines mask symptoms but don't address root cause
• Need to taper Xanax while addressing ADHD
• Bupropion can help ADHD symptoms and reduce executive-dysfunction-driven anxiety

Treatment:

• Wellbutrin XL 150mg × 4 weeks, then 300mg
• Xanax taper over 6 weeks (slow due to 6-month daily use)
• CBT for ADHD skills (time management, task breakdown)

Outcome at 12 weeks:

• Off Xanax completely
• Executive function significantly improved on Wellbutrin 300mg
• "Overwhelm anxiety" 70% improved
• Can initiate and complete tasks without deadline panic
• Still has some anxiety, but manageable

Why Wellbutrin worked: ADHD symptoms improved, reducing the secondary anxiety. Bupropion addressed the root cause that benzos only masked.

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Case 3: Panic Disorder

Presentation: 42-year-old woman, sudden-onset panic attacks 3 months ago. Multiple ER visits for "heart attack" - all cardiac workup normal. Now having 2-3 panic attacks per week, avoiding situations that trigger them.

Medical workup: EKG normal, Holter monitor normal, thyroid normal, all other labs normal.

Clinical reasoning:

• Classic panic disorder presentation
• First-line: SSRI + CBT
• Wellbutrin NOT appropriate (can worsen panic)
• Benzodiazepines appropriate SHORT-TERM while SSRI takes effect

Treatment:

• Lexapro 10mg daily (SSRI for panic disorder)
• Ativan 0.5mg as-needed during panic attacks (maximum 1x/day)
• Ativan 0.5mg at bedtime for first 3 weeks (bridge while Lexapro starts working)
• Referral to CBT therapist specializing in panic disorder
• Gradual taper of Ativan starting week 4

Outcome at 8 weeks:

• Lexapro at full effect
• Panic attacks reduced to 1 every 2-3 weeks
• Ativan discontinued at week 6
• Continuing Lexapro + CBT
• Now using CBT breathing techniques during panic instead of medication

Why benzodiazepines worked here: Short-term bridge therapy during SSRI startup. Appropriate, time-limited use.

Why Wellbutrin would have failed: Bupropion can worsen panic disorder. Wrong mechanism for this patient.

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Case 4: Situational Anxiety (Medical Phobia)

Presentation: 50-year-old man, severe anxiety about medical procedures. Needs colonoscopy but has avoided for 2 years due to panic about sedation. Otherwise healthy, no daily anxiety.

Medical workup: Not needed (isolated situational anxiety, no medical factors).

Clinical reasoning:

• Isolated, predictable trigger (medical procedures)
• Not daily/ongoing anxiety disorder
• Doesn't need daily medication
• Benzodiazepine appropriate for single-use situations

Treatment:

• Ativan 1mg one hour before colonoscopy
• Additional 0.5mg if needed during prep
• No daily medication
• Discussed CBT for medical phobia if procedures become more frequent

Outcome:

• Completed colonoscopy successfully
• No further benzodiazepine use needed
• No dependence risk (single-use scenario)

Why benzodiazepine was appropriate: Rare, predictable trigger. Not ongoing daily use.

Why Wellbutrin would be absurd: Doesn't need weeks of daily medication for a single-day procedure.

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Success Story: From Benzodiazepine Dependence to Sustainable Relief

Marcus, a 41-year-old software engineer, came in after three years of daily Xanax use. His original prescriber had started him on 0.5mg as-needed for work presentations. Within six months, he was taking 1mg three times daily just to feel "normal."

"My anxiety is worse than before I started," he said. "And now I'm terrified to stop because the withdrawal is unbearable."

His labs showed low ferritin (24 ng/mL) and vitamin D (18 ng/mL) - both contributing to his fatigue and anxiety. The comprehensive workup also revealed significant ADHD symptoms that had never been evaluated.

The treatment plan:

1. Slow benzodiazepine taper (10% reduction every 2 weeks)

2. Start Wellbutrin XL 150mg during the taper

3. Iron supplementation and vitamin D3 5,000 IU daily

4. CBT for anxiety management during transition

At 16 weeks: Marcus was completely off Xanax for the first time in three years. His anxiety was 60% improved - not perfect, but manageable without dependence. His ferritin was 72 ng/mL, vitamin D at 48 ng/mL. Most importantly, he could function at work and actually feel his emotions again.

"For the first time in years, I feel like myself," he said. "Not numb, not sedated, not anxious about running out of medication."

This outcome required patience - benzodiazepine tapers take months, not weeks. But addressing the underlying causes (ADHD, nutritional deficiencies) while slowly discontinuing the benzodiazepine created sustainable improvement.

The Wellbutrin Timeline: What to Actually Expect

If you and your provider decide Wellbutrin is appropriate, here's the realistic timeline:

Week 1-2: The Activation Phase

What you might feel:

• Increased energy (can feel jittery)
• Initial anxiety or nervousness
• Difficulty falling asleep
• Dry mouth
• Decreased appetite
• Some patients feel "speedy" or "wired"

What to do:

• Take in the morning (reduces insomnia)
• Expect this phase - it usually improves
• Use relaxation techniques, deep breathing
• If truly intolerable: Call provider (might use short-term benzo bridge or reduce dose)

Why this happens:

Your brain is adjusting to higher dopamine and norepinephrine. This activation is temporary for most patients.

Week 3-4: Stabilization

What you might feel:

• Jitteriness usually subsides
• Energy feels more "normal" and less "wired"
• Mood starting to lift (if depression present)
• Anxiety about same or slightly improved

What to do:

• Continue medication consistently
• Track mood and anxiety daily (1-10 scale)
• Report any concerning symptoms to provider

Week 6-8: Therapeutic Effect

What you might feel:

• If Wellbutrin is going to work, this is when you'll notice:
• Improved motivation and follow-through
• Better ability to manage stress without overwhelm
• More emotional resilience
• Reduced fatigue-driven anxiety
• Improved focus (if ADHD component present)

What to do:

• Assess: Is this working?
• If yes: Continue current dose
• If partial response: Provider may increase dose to 300mg or 450mg
• If no response or worse: Discuss alternative medications

Month 3+: Maintenance

What you might feel:

• Sustained improvement in mood, energy, focus
• Anxiety at new baseline (lower than before)
• Minimal side effects (most resolve by this point)

What to do:

• Continue monitoring
• Discuss any remaining symptoms
• Plan for how long to stay on medication

Sexual Side Effects: The Hidden Reason People Switch

Here's something most providers gloss over: 30-40% of patients on SSRIs develop sexual side effects - decreased libido, difficulty with arousal, delayed or absent orgasm, erectile dysfunction.

These side effects often don't improve, even after months on the medication. For many patients, this is a deal-breaker.

Why this matters for the Wellbutrin vs. benzodiazepine discussion:

If you're on an SSRI for anxiety and it's working - but you've lost your sex drive or can't have an orgasm - you have options:

Option 1: Switch to Wellbutrin

• Bupropion does NOT cause sexual side effects
• In fact, it's sometimes added to SSRIs to REDUCE their sexual side effects
• If your anxiety is really anxious depression, Wellbutrin alone may be sufficient

Option 2: Add Wellbutrin to your SSRI

• Combining medications can offset SSRI sexual dysfunction
• Maintains SSRI anxiety relief while restoring sexual function
• Requires careful monitoring (seizure risk slightly higher with combinations)

Option 3: Switch to a different SSRI

• Sometimes switching from Lexapro to Zoloft, or vice versa, reduces sexual side effects
• Not always effective, but worth trying before abandoning SSRIs entirely

What NOT to do: Switch to benzodiazepines for ongoing daily anxiety because of SSRI sexual side effects. Benzos don't treat the root anxiety disorder, and dependence risk is high.

The key point: Sexual side effects are a legitimate reason to reconsider your medication regimen. Don't suffer in silence. Bring it up with your provider.

What Your Provider Should Be Asking (But Might Not)

Before prescribing either Wellbutrin or benzodiazepines for anxiety, comprehensive evaluation should include:

Diagnostic Clarity

1. Is this primary anxiety or secondary anxiety?

• Primary: Anxiety disorder (GAD, panic disorder, social anxiety)
• Secondary: Anxiety due to depression, ADHD, medical condition, substance use

2. What type of anxiety?

• Generalized worry vs. panic attacks vs. social phobia vs. PTSD
• Different anxiety types respond to different treatments

3. What's the timeline?

• Sudden onset vs. lifelong
• Continuous vs. episodic
• Triggered vs. unprovoked

Medical Investigation

4. Have we ruled out medical causes?

• Thyroid disorder
• Cardiac issues
• Anemia or nutritional deficiencies
• Hormonal imbalances
• Substance use or withdrawal

5. What medications are you currently taking?

• Some medications CAUSE anxiety (stimulants, steroids, thyroid medication, decongestants)
• Stopping some medications causes withdrawal anxiety (SSRIs, SNRIs, benzodiazepines)

Treatment History

6. What have you already tried?

• Previous medications and responses
• Therapy (CBT, exposure therapy, EMDR)
• Lifestyle interventions (exercise, sleep optimization, stress management)

7. What's your substance use history?

• Alcohol use (can mimic or worsen anxiety)
• Cannabis (can worsen anxiety in some people)
• History of substance use disorder (benzodiazepines may be contraindicated)

Functional Impact

8. How is anxiety affecting your life?

• Work performance
• Relationships
• Daily functioning
• Quality of life

9. What are your goals?

• Complete elimination of anxiety (unrealistic)
• Manageable anxiety that doesn't interfere with life (realistic)
• Ability to function without constant medication (depends on severity)

If your provider isn't asking these questions, they're not conducting a comprehensive assessment.

When to Choose Wellbutrin Over Benzodiazepines

Based on 19 years of clinical experience, here's when I recommend Wellbutrin instead of benzodiazepines:

1. Anxious Depression

• Depression is primary, anxiety is secondary
• You need both mood and anxiety addressed
• SSRIs caused sexual side effects

2. ADHD-Driven Anxiety

• Overwhelm from executive dysfunction
• Procrastination-induced panic
• Task management creates constant stress
• Benzodiazepines would mask but not fix the problem

3. Fatigue + Anxiety

• "Tired but wired" feeling
• SSRIs made you too sedated
• Need activation, not sedation

4. Long-Term Treatment Goal

• Need sustainable, non-habit-forming medication
• Benzodiazepines aren't appropriate for chronic daily use
• Willing to wait 6-8 weeks for full effect

5. History of Substance Use

• Previous addiction or dependence on alcohol, opioids, or benzos
• Higher risk for benzodiazepine dependence
• Wellbutrin has no abuse potential

When to Choose Benzodiazepines Over Wellbutrin

Despite the risks, benzodiazepines have legitimate uses:

1. Acute Panic Attacks

• Need immediate relief (30-60 minutes)
• As-needed use only (not daily)
• Paired with CBT or SSRI for long-term management

2. Bridge Therapy

• Starting SSRI or SNRI for anxiety
• Need relief during 4-8 week startup period
• Short-term use only (2-4 weeks max)

3. Severe Situational Anxiety

• Flying phobia, medical procedures, rare predictable triggers
• Maximum a few times per year
• Not for daily ongoing anxiety

4. Panic Disorder with Severe Acute Episodes

• While establishing longer-term treatment
• Rescue medication for breakthrough panic
• Time-limited use with clear taper plan

5. When Wellbutrin Is Contraindicated

• History of seizures
• Eating disorder (current or past)
• Abrupt benzodiazepine or alcohol withdrawal underway

The Medical Investigation I Recommend

Before prescribing psychiatric medication for anxiety, I order:

Standard Panel:

• TSH, Free T4, Free T3 (thyroid)
• CBC (rule out anemia)
• CMP (kidney, liver, glucose, electrolytes)
• Ferritin (iron stores) - must be >50 ng/mL, optimal >75
• Vitamin D (25-OH) - target 40-60 ng/mL
• B12 - optimal >600 pg/mL
• HbA1c (blood sugar control)

Sex-Specific:

• Women with menstrual changes or age 35+: FSH, LH, Estradiol (day 3 of cycle)
• Men with low libido or fatigue: Testosterone (total and free, drawn 7-9am), SHBG

Based on Symptoms:

• If palpitations: EKG, consider Holter monitor
• If GI symptoms: Consider celiac panel
• If fatigue is severe: CRP (inflammation), cortisol (7-9am draw)

Why this matters:

If your ferritin is 22, your TSH is 3.8, and your vitamin D is 18 - those are all contributing to your anxiety. Optimizing these often reduces anxiety significantly, sometimes eliminating the need for psychiatric medication entirely.

Many psychiatrists skip this step. I don't. The medical investigation is often where we find the real answers.

What Most People Get Wrong

Let me correct the most common misconceptions:

Misconception 1: "Wellbutrin is for depression, not anxiety"

Reality: Wellbutrin can help anxiety when:

• Anxiety is secondary to depression
• ADHD symptoms are driving overwhelm-based anxiety
• Fatigue and low motivation are creating anxiety
• SSRIs caused intolerable side effects

It does NOT help panic disorder or pure GAD in most cases.

Misconception 2: "Benzodiazepines are safe if taken as prescribed"

Reality: Even when taken exactly as prescribed, 44% of regular users develop dependence after 4+ weeks. "As prescribed" doesn't mean "risk-free."

Misconception 3: "I can just take Xanax when I feel anxious"

Reality: As-needed use sounds reasonable, but if "as needed" becomes daily (or multiple times daily), you're on the path to dependence. Most providers recommend maximum 2-3 times per week for as-needed use.

Misconception 4: "Wellbutrin will make my anxiety worse"

Reality: For some patients, yes - especially those with panic disorder. But for others (anxious depression, ADHD-driven anxiety), it helps significantly. The key is proper patient selection and managing expectations about the first 2-3 weeks.

Misconception 5: "I can stop benzos anytime since my dose is low"

Reality: Even low doses can cause dependence after weeks of daily use. Stopping abruptly can trigger severe rebound anxiety and, in some cases, seizures. Always taper under medical supervision.

The Bottom Line: Making the Right Choice

Here's how I approach this decision with patients:

Start with the diagnosis:

• Pure anxiety disorder (GAD, panic, social anxiety) → SSRIs are first-line, not Wellbutrin or benzos
• Anxious depression → Wellbutrin is reasonable first-line
• ADHD-driven anxiety → Wellbutrin or stimulants, NOT benzos
• Acute panic with need for immediate relief → Short-term benzodiazepines appropriate
• Chronic daily anxiety → Never chronic benzodiazepines

Consider the timeline:

• Need immediate relief? → Benzodiazepines work in 30-60 minutes
• Can wait 6-8 weeks? → Wellbutrin (or SSRIs) work gradually but sustainably

Assess the risks:

• History of substance use? → Avoid benzodiazepines
• History of seizures? → Avoid Wellbutrin
• Sexual side effects from SSRIs? → Wellbutrin is good alternative

Think long-term:

• Sustainable medication for months/years? → Wellbutrin
• Short-term crisis management (days/weeks)? → Benzodiazepines

Optimize medical factors FIRST:

• Check thyroid, iron, vitamin D, hormones
• Treat deficiencies before adding psych medications
• You might not need medication at all if medical factors resolve

What to Discuss With Your Provider

If you're considering either medication, bring these questions to your appointment:

About your diagnosis:

1. "Do I have primary anxiety, or is my anxiety secondary to something else (depression, ADHD, medical condition)?"

2. "What type of anxiety disorder do I have specifically?"

3. "What medical conditions should we rule out before starting psychiatric medication?"

About Wellbutrin:

4. "Is Wellbutrin appropriate for my type of anxiety?"

5. "What should I expect in the first few weeks? Will my anxiety get worse before it gets better?"

6. "If I have initial activation or anxiety, what's the plan?"

7. "How will we know if it's working by week 6-8?"

About benzodiazepines:

8. "Am I a candidate for short-term benzodiazepines, or is this for long-term use?"

9. "If I start taking this daily, how will we prevent dependence?"

10. "What's the plan for tapering off? When do we start?"

11. "Are there alternatives to benzodiazepines for my situation?"

About treatment overall:

12. "Are we addressing root causes, or just managing symptoms?"

13. "What labs should we check to rule out medical factors?"

14. "Should I also be in therapy (CBT) while on medication?"

These questions demonstrate you're informed and engaged. Any good provider will welcome this discussion.

My Approach at Horizon Peak Health

When patients come to me with anxiety, here's my process:

First visit (75-90 minutes):

• Comprehensive medical and psychiatric history
• Systematic review of all body systems
• Rule out ADHD, depression, medical factors
• Order full lab panel
• Discuss timeline and goals

Lab review visit (2-3 weeks later):

• Review all labs together
• Identify what needs optimizing (thyroid, iron, vitamin D, hormones)
• Start medical optimization
• Discuss medication options if needed
• Clear explanation of Wellbutrin vs. SSRIs vs. benzodiazepines

Follow-up (monthly during optimization):

• Track response to medical interventions
• Add psychiatric medication if needed (often Wellbutrin for anxious depression, SSRI for pure anxiety)
• Use benzodiazepines SHORT-TERM if bridging during SSRI startup
• Adjust based on response

Goal:

Most patients feel significantly better within 2-3 months once we identify and treat all contributing factors - medical, psychiatric, and lifestyle.

Not everyone needs psychiatric medication. But when they do, we choose the right one based on their specific presentation, not a one-size-fits-all approach.

Final Thoughts: There's No Universal "Better" Medication

The question "Is Wellbutrin or benzodiazepines better for anxiety?" has no universal answer.

It's like asking "Is a scalpel or antibiotics better for infection?"

The answer is: Depends on the infection.

• Skin abscess? → Scalpel (drain it)
• Pneumonia? → Antibiotics
• Both present? → Both interventions

Anxiety is the same:

• Anxious depression? → Wellbutrin
• Acute panic attack? → Benzodiazepine (short-term)
• Chronic panic disorder? → SSRI + CBT, NOT chronic benzos
• ADHD-driven overwhelm? → Wellbutrin or stimulant
• Medical factors causing anxiety? → Address the medical issue first

After 19 years in ICU medicine, I learned that the most important question isn't "Which medication?" - it's "What's actually causing this?"

When you have the right diagnosis and you've ruled out medical factors, the medication choice becomes clear.

If you're dealing with anxiety and your provider isn't asking these questions, you deserve a more thorough investigation.

The goal isn't to medicate symptoms away. The goal is to understand WHY you're anxious, address root causes, and use medication strategically when genuinely needed.

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Getting Started: What to Expect

A comprehensive psychiatric evaluation that investigates root causes typically includes:

• Initial assessment: 75-90 minutes reviewing your complete medical and psychiatric history
• Lab workup: Thyroid, iron, vitamin D, B12, and other factors that mimic or worsen anxiety
• Treatment planning: Clear recommendations based on your specific presentation
• Follow-up visits: 30-minute monthly appointments to monitor progress and adjust treatment

Investment: Initial evaluation and follow-ups covered by most insurance plans (cash rates: $350-450 initial, $150-200 follow-ups; sliding scale available for uninsured). Lab work typically $20 copay with insurance.

Need a thorough evaluation that investigates root causes? Horizon Peak Health offers comprehensive assessments that include medical investigation, not just symptom management. Serving Rancho Palos Verdes, Phoenix, Chandler, and telehealth throughout California and Arizona.

Los Angeles and Phoenix | Telehealth Available

(310) 955-1041

Book Your Consultation →

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Disclaimer: This article is for educational purposes only and does not constitute medical advice. Medication decisions should be made in consultation with your healthcare provider based on your individual medical history and current health status. Never start, stop, or change psychiatric medications without medical supervision. Abruptly stopping benzodiazepines can be dangerous.

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References

Pollack, M. H., Simon, N. M., Zalta, A. K., Worthington, J. J., Hoge, E. A., Mick, E., ... & Otto, M. W. (2006). Olanzapine augmentation of fluoxetine for refractory generalized anxiety disorder: a placebo controlled study. Biological Psychiatry, 59(3), 211-215.

Ait-Daoud, N., Hamby, A. S., Sharma, S., & Blevins, D. (2018). A review of alprazolam use, misuse, and withdrawal. Journal of Addiction Medicine, 12(1), 4-10.

Stahl, S. M. (2021). Stahl's Essential Psychopharmacology: Neuroscientific Basis and Practical Applications (5th ed.). Cambridge University Press.

Lader, M. (2011). Benzodiazepines revisited—will we ever learn? Addiction, 106(12), 2086-2109.