What other medications can be taken with escitalopram (SSRI) for depression?

Medications That Can Be Taken With Escitalopram for Depression

For patients taking escitalopram who need additional medication for depression, bupropion, mirtazapine, or venlafaxine can be safely added as augmentation therapy, with the choice depending primarily on the patient's symptom profile and tolerability concerns. 1

Evidence-Based Medication Options

When escitalopram alone is not providing adequate relief for depression, several second-generation antidepressants can be considered as augmentation therapy:

First-Line Augmentation Options:

1. Bupropion

   • Benefits: Lower rate of sexual dysfunction compared to other options 1
   • Best for: Patients with fatigue, low energy, or sexual side effects from escitalopram
   • Evidence: STAR*D trial showed 1 in 4 patients became symptom-free after switching to bupropion 1

2. Mirtazapine

   • Benefits: Faster onset of action than other antidepressants 1
   • Best for: Patients with insomnia and poor appetite
   • Mechanism: SNRI (Serotonin Norepinephrine Reuptake Inhibitor)
   • Evidence: Significantly faster onset of action than citalopram, fluoxetine, paroxetine, or sertraline 1

3. Venlafaxine (extended-release)

   • Benefits: May be more effective for anxiety symptoms 1
   • Best for: Patients with prominent anxiety
   • Mechanism: SNRI
   • Evidence: STAR*D trial showed comparable efficacy to bupropion for treatment-resistant depression 1

Clinical Decision Algorithm

Step 1: Assess current symptoms and side effects

• If sexual dysfunction is present → Consider bupropion
• If insomnia/appetite issues are prominent → Consider mirtazapine
• If anxiety is predominant → Consider venlafaxine

Step 2: Check for contraindications

• Review for potential drug interactions with escitalopram
• Avoid MAOIs (contraindicated with escitalopram) 2
• Avoid pimozide (contraindicated with escitalopram) 2

Step 3: Monitor for serotonin syndrome

• When combining escitalopram with other serotonergic agents (particularly venlafaxine), monitor for:
  • Mental status changes (agitation, hallucinations)
  • Autonomic instability (tachycardia, hyperthermia)
  • Neuromuscular symptoms (tremor, rigidity)
  • Gastrointestinal symptoms (nausea, diarrhea) 2

Important Considerations

Efficacy

• No significant differences in efficacy between second-generation antidepressants for treating major depression 1
• Approximately 38% of patients do not achieve treatment response during 6-12 weeks of treatment with a single second-generation antidepressant 1
• 54% do not achieve remission with initial treatment 1

Timing

• Allow 6-8 weeks to assess full response to escitalopram before augmenting 1
• When adding a second agent, expect approximately 25% chance of becoming symptom-free 1

Safety Precautions

• Avoid combining escitalopram with:

  • MAOIs (risk of serotonin syndrome)
  • Pimozide
  • Medications that impair serotonin metabolism 2

• Monitor closely when combining with:

  • Triptans
  • Tricyclic antidepressants
  • Tramadol
  • St. John's Wort 2

Common Pitfalls to Avoid

1. Adding a second agent too soon - Allow 6-8 weeks for escitalopram to reach full effect before augmenting
2. Ignoring symptom profile - Match the augmentation agent to the patient's specific symptoms
3. Overlooking drug interactions - Always check for potential interactions between escitalopram and the augmenting agent
4. Failing to monitor for serotonin syndrome - This is especially important when combining multiple serotonergic medications
5. Not adjusting doses gradually - When adding a second agent, start at a low dose and titrate slowly

Remember that augmentation therapy increases the risk of side effects and drug interactions. Regular monitoring is essential, especially during the initial weeks of combination treatment.