How can I safely restart Lexapro (escitalopram), Depakote (valproate), clonidine, guanfacine, Risperidone (risperidone), melatonin, and hydroxyzine in a patient who has been off these medications for two months?

Restarting Multiple Psychiatric Medications After Two Months Discontinuation

For an 18-year-old patient who has been off multiple psychiatric medications for two months, restart medications gradually beginning with the most critical medications for symptom control, such as risperidone, at lower doses than previously prescribed, then gradually titrate up while monitoring for side effects and therapeutic response. 1

Prioritization and Sequence of Medication Restart

• Begin with the antipsychotic medication (risperidone) as the first priority, starting at 50% of the previous dose and gradually increasing by 0.5mg every 2-4 weeks until reaching the target therapeutic dose 1, 2
• Next, restart mood stabilizer (Depakote/valproate) at a lower dose than previously prescribed, with gradual titration to minimize side effects 3
• Follow with alpha-2 agonists (clonidine and guanfacine) at lower doses, as abrupt discontinuation of these medications can lead to rebound hypertension and tachycardia 3, 4
• Restart escitalopram (Lexapro) at a lower dose, with gradual titration to avoid withdrawal symptoms such as anxiety, irritability, dizziness, and electric shock-like sensations 5
• Finally, add hydroxyzine as needed for anxiety/sleep and melatonin based on sleep patterns 1

Specific Medication Restart Guidelines

Risperidone

• Start with 0.5-1 mg once daily (50% of previous dose), then increase by 0.5 mg every 2-4 weeks to target dose 1, 2
• Monitor for extrapyramidal symptoms, sedation, and metabolic effects 2

Depakote (Valproate)

• Begin at a lower dose (typically 250 mg daily) and gradually increase while monitoring serum levels 3
• Check liver function tests and complete blood count before restarting 3

Clonidine and Guanfacine

• Restart at lower doses (clonidine 0.1 mg once daily; guanfacine 0.5-1 mg once daily) 3, 4
• Titrate slowly to avoid rebound hypertension, which can occur with abrupt discontinuation 3
• Monitor blood pressure and heart rate during dose adjustments 4, 6
• Be aware that sedation is a common side effect mediated by central alpha-2 adrenergic receptors 4, 7

Escitalopram (Lexapro)

• Begin at 5 mg daily (50% of typical adult starting dose) 5
• Increase gradually over 2-4 weeks to target dose 5
• Monitor for activation of mania/hypomania, suicidal thoughts, and serotonin syndrome 5
• Be aware that SSRIs can cause sexual dysfunction as a side effect 5

Hydroxyzine and Melatonin

• These can be restarted as needed after the initial restart of critical medications 1
• Hydroxyzine can be used as needed for anxiety or sleep 1
• Evaluate the need for melatonin based on current sleep patterns 1, 8

Monitoring Parameters

• Schedule follow-up within 2 weeks of initiating the first medication to assess efficacy and side effects 1
• Monitor for withdrawal symptoms, which may include insomnia, anxiety, irritability, or exacerbation of original symptoms 1, 9
• If withdrawal symptoms occur, consider temporarily returning to the previous dose and attempting a smaller reduction after symptoms stabilize 1, 9
• Assess for drug-drug interactions, particularly between escitalopram and other medications 5

Common Pitfalls to Avoid

• Not providing adequate follow-up during the medication restart process, which should occur within 2 weeks of initiating therapy 1
• Restarting all medications simultaneously, which can make it difficult to attribute side effects to specific medications 3
• Overlooking withdrawal symptoms that may be mistaken for worsening of the underlying psychiatric conditions 1, 9
• Failing to recognize potential drug interactions, especially with multiple psychotropic medications 5
• Not involving the patient in the medication restart plan, which can lead to poor adherence 3, 1

Special Considerations

• Clearly communicate the restart plan to the patient and caregivers to promote adherence 1
• Simplify the regimen where possible to improve adherence 1
• Consider the risk of relapse when restarting medications after discontinuation, as seen in patients with schizophrenia who discontinue antipsychotics 3
• Be aware that some medications (particularly SSRIs and alpha-2 agonists) can cause discontinuation syndromes when stopped abruptly 3