Is it possible to augment Lexapro (escitalopram) with buspirone?

Augmenting Escitalopram with Buspirone for Major Depressive Disorder

Yes, buspirone is an effective augmentation strategy for escitalopram (Lexapro) in patients with major depressive disorder who have had an inadequate response to escitalopram monotherapy. 1

Evidence for Buspirone Augmentation

The STAR*D (Sequenced Treatment Alternatives to Relieve Depression) trial, one of the largest and most comprehensive studies on depression treatment strategies, demonstrated that augmenting citalopram (which is closely related to escitalopram) with buspirone showed similar efficacy to other augmentation strategies, including bupropion SR and cognitive therapy 1.

Key findings from the evidence:

• Buspirone augmentation showed comparable response and remission rates to other augmentation strategies 1
• In open trials, 59% of patients showed complete or partial remission when buspirone was added to SSRI therapy, including citalopram 2
• Buspirone doses of 20-30 mg/day are typically effective for augmentation 2

Practical Implementation

Dosing Strategy

• Start buspirone at 5-10 mg twice daily
• Gradually increase to 20-30 mg/day in divided doses
• Maximum dose typically 60 mg/day, though most patients respond to 20-30 mg/day 2

Monitoring Parameters

• Assess for clinical improvement in depressive symptoms within 2-4 weeks
• Monitor for potential side effects, particularly:
  • Dizziness
  • Headache
  • Nervousness
  • Lightheadedness 3
• Watch for signs of serotonin syndrome when combining with escitalopram (mental status changes, autonomic instability, neuromuscular symptoms) 4

Advantages of Buspirone Augmentation

1. Safety profile: Buspirone has minimal sedation effects and lacks anticonvulsant and muscle-relaxant properties 3
2. Low abuse potential: No reports of dependence or withdrawal symptoms 3
3. Minimal drug interactions: Generally well-tolerated when combined with SSRIs 2
4. Efficacy in elderly: Well-tolerated in older adults, even with multiple medical conditions 5

Important Considerations and Caveats

• Discontinuation due to adverse events was higher with buspirone (20.6%) compared to bupropion SR (12.5%) in the STAR*D trial 1
• Some evidence suggests bupropion may decrease depression severity more effectively than buspirone as an augmentation strategy 1, 6
• Buspirone's mechanism involves 5-HT1A receptors, which may complement the serotonergic effects of escitalopram 3
• Long-term efficacy: 79% of initial responders who remained on augmentation therapy for at least 4 months remained symptom-free at follow-up 2

Alternative Augmentation Strategies

If buspirone augmentation is ineffective or poorly tolerated, consider:

1. Bupropion augmentation (may have lower discontinuation rates due to adverse events) 1
2. Cognitive therapy augmentation (similar efficacy to medication augmentation with fewer side effects) 1
3. Switching to a different antidepressant class 1

Conclusion

Buspirone augmentation of escitalopram is a well-established, evidence-based strategy for patients with major depressive disorder who have had an inadequate response to escitalopram monotherapy. The combination is generally well-tolerated, though careful monitoring for adverse effects is necessary, particularly for signs of serotonin syndrome.