Consistent differential effects of bupropion and mirtazapine in major depression

Abstract

Background

Patients with major depression exhibit heterogeneous symptom profiles and variable responses to antidepressants. Most clinical trials rely on aggregate outcomes such as total symptom severity or remission rates, which often obscure meaningful differences in treatment response.

Methods

We applied the Supervised Varimax (SV) algorithm to identify outcome dimensions that maximally differentiate antidepressants based on symptom-level effects. We analyzed all relevant levels of the STAR*D trial and validated findings in the independent CO-MED study. We assessed statistical significance using permutation testing with familywise error rate (FWER) correction.

Results

SV consistently identified interpretable and statistically significant differences between bupropion, mirtazapine, and other antidepressants. In STAR*D, bupropion monotherapy produced greater improvement in hypersomnia than venlafaxine in Levels 2 and 2 A ($n=686$, difference = $0.384$, $p_{\mathrm{FWER}}=0.007$). Bupropion augmentation outperformed buspirone augmentation for increased weight, increased appetite, and fatigue in Level 2 ($n=520$, difference = $-0.322$, $p_{\mathrm{FWER}}=0.005$). Mirtazapine monotherapy outperformed nortriptyline for insomnia, decreased weight, and decreased appetite in Level 3 ($n=214$, difference = $0.401$, $p_{\mathrm{FWER}}=0.022$), and venlafaxine with mirtazapine similarly outperformed tranylcypromine in Level 4 ($n=102$, difference = $-0.722$, $p_{\mathrm{FWER}}=0.004$). In CO-MED, escitalopram with bupropion and venlafaxine with mirtazapine demonstrated complementary symptom-specific benefits ($n=640$, difference = $-0.302$, $p_{\mathrm{FWER}}=0.022$).

Conclusion

Bupropion is most effective for hypersomnia, increased weight, increased appetite, or fatigue, while mirtazapine is preferable for insomnia, decreased weight, or decreased appetite. SV enables statistically rigorous, symptom-level differentiation using only treatment assignment, offering a scalable and clinically aligned framework for guiding antidepressant selection from individual clinical trials.