What is the next step for a patient currently on Lexapro (escitalopram) 20mg with worsening symptoms?

Managing Worsening Symptoms in a Patient on Lexapro 20mg

For a patient currently on Lexapro (escitalopram) 20mg with worsening symptoms, the next step should be switching to a different antidepressant, with duloxetine (SNRI) being the most appropriate choice based on evidence for improved efficacy in patients who fail to respond to SSRIs.

Assessment of Current Situation

• First, confirm that the patient has been taking escitalopram 20mg consistently for at least 6-8 weeks, as this is the minimum duration needed to assess adequate response 1
• Evaluate for potential causes of worsening symptoms:
  • Medication adherence issues 1
  • Development of side effects (especially sexual dysfunction, which is common with SSRIs) 1
  • Emergence of new stressors or comorbid conditions 1

Switching Medication Approach

Recommended Next Agent: Duloxetine (SNRI)

• SNRIs like duloxetine have shown slightly better efficacy than SSRIs in patients who did not respond adequately to initial SSRI treatment 1
• Start duloxetine at 30mg once daily for one week, then increase to 60mg once daily 1
• Maximum dosage can be up to 60mg twice daily if needed 1
• A 4-week trial at the target dose is recommended to evaluate effectiveness 1

Alternative Option: Venlafaxine (SNRI)

• Start at 37.5mg once or twice daily 1
• Increase by 75mg each week as tolerated 1
• Target dose of 225mg/day 1
• Requires 4-6 weeks for adequate trial 1

Cross-Titration Method

• Begin the new antidepressant while gradually tapering escitalopram to minimize withdrawal symptoms 1
• Taper escitalopram over 10-14 days to limit withdrawal effects 1
• Monitor for potential serotonin syndrome during the overlap period, especially when switching to another serotonergic agent 2

Monitoring During Transition

• Schedule follow-up within 1-2 weeks of initiating the medication change 1
• Assess for:
  • Emergence of suicidal thoughts (particularly important in patients under 24 years) 2
  • Withdrawal symptoms from escitalopram (anxiety, irritability, dizziness, electric shock-like sensations) 2
  • Side effects of the new medication 1

Special Considerations

• If the patient has significant anxiety symptoms, venlafaxine may be particularly beneficial 1
• For patients with comorbid pain symptoms, duloxetine has additional benefits for pain management 1
• If sexual dysfunction was a significant issue with escitalopram, bupropion may be considered as it has lower rates of sexual side effects 1
• For elderly patients, use lower starting doses and slower titration schedules 1

If SNRI Switch Is Unsuccessful

• Consider a trial of bupropion, which has a different mechanism of action 1

  • Start at 37.5mg every morning, then increase by 37.5mg every 3 days 1
  • Target dose of 150mg twice daily 1
  • Bupropion is activating and may improve energy levels 1

• Alternatively, consider mirtazapine:

  • Start at 7.5mg at bedtime 1
  • Target dose of 30mg at bedtime 1
  • Particularly helpful if insomnia, poor appetite, or weight loss are issues 1

Remember that the goal is to achieve remission of depressive symptoms, not just partial improvement. If symptoms continue to worsen despite medication changes, consider referral to a psychiatrist for more specialized care 1.