What is the best course of action for a 60-year-old patient on Lexapro (escitalopram) 20mg, Lamictal (lamotrigine) 150mg, and Hydroxyzine (hydroxyzine) 75mg for sleep, who reports mania and falls over the past 3 days?

Immediate Management of Acute Mania with Falls in a Patient on Lexapro and Lamictal

Discontinue Lexapro immediately, as SSRIs can precipitate and worsen manic episodes in bipolar disorder, and initiate an antipsychotic for acute mania control while addressing fall risk. 1

Critical First Steps

Discontinue the Antidepressant

• Escitalopram (Lexapro) must be stopped immediately as it can activate mania or hypomania in patients with bipolar disorder 1
• The FDA label explicitly warns that treating a depressive episode with escitalopram in bipolar patients may precipitate a mixed/manic episode 1
• Taper is not necessary in this acute manic crisis—immediate discontinuation is appropriate 1

Address the Inadequate Mood Stabilizer Coverage

• Lamotrigine 150 mg is not effective for acute mania—it has demonstrated no efficacy in treating acute manic episodes and is only useful for preventing depressive episodes 2, 3
• Lamotrigine itself can induce mania, particularly in patients with bipolar I disorder, manic predominant polarity, or history of antidepressant-induced switches 4
• The current dose of 150 mg is subtherapeutic even for maintenance (target is typically 200 mg), but this is irrelevant since it doesn't treat acute mania 2

Acute Pharmacological Management

Initiate Antipsychotic Therapy

• Start quetiapine (Seroquel) 100-200 mg immediately, titrating by 100-200 mg every 1-2 days toward 400-800 mg daily for acute mania with any psychotic features 5
• Alternative first-line options include olanzapine 10-15 mg daily or risperidone 2-3 mg daily 6, 7
• Aripiprazole 15 mg daily is another evidence-based option with FDA approval for acute mania 6

PRN Medication for Breakthrough Agitation

• Haloperidol 0.5-2 mg PO/IM every 1 hour as needed provides rapid control of acute agitation and should be used during the antipsychotic titration period 5, 8
• Start with 0.5-1 mg doses in this 60-year-old patient and titrate based on response 5
• Avoid benzodiazepines as monotherapy—they do not treat the underlying manic psychosis and increase fall risk significantly 6
• If benzodiazepines are absolutely necessary for refractory agitation despite adequate antipsychotic dosing, use lorazepam 0.25-0.5 mg (lower doses for elderly) only as adjunctive therapy 6, 8

Fall Risk Management

Medication-Related Fall Risk

• Hydroxyzine 75 mg is contributing to fall risk through sedation, dizziness, and orthostatic hypotension—consider discontinuing or reducing significantly 6
• The combination of hydroxyzine with newly initiated antipsychotics will compound sedation and fall risk 6
• Antipsychotics, sedative/hypnotics, and anticholinergics are all high-risk medications for falls in older adults 6

Environmental and Safety Interventions

• Implement immediate fall precautions: bedside commode, non-skid surfaces, adequate lighting, removal of trip hazards 6
• Perform orthostatic blood pressure measurements given the medication regimen 6
• Assess gait and perform a "get up and go test" before any discharge consideration 6
• Consider admission if patient safety cannot be ensured at home, particularly given the 3-day history of falls 6

Monitoring and Follow-Up

Short-Term Monitoring (First Week)

• Monitor daily for manic symptom control, medication side effects (extrapyramidal symptoms, sedation, orthostatic hypotension), and fall recurrence 6, 5
• Therapeutic antimanic effects typically require 400-800 mg daily of quetiapine and 1-2 weeks to manifest fully 5
• Use haloperidol PRN during this titration period to manage breakthrough symptoms 5

Longer-Term Considerations

• Once acute mania resolves, reassess the need for lamotrigine—it may need to be discontinued given its potential to induce mania and lack of antimanic efficacy 2, 3, 4
• Consider lithium as an alternative mood stabilizer with proven efficacy for both acute mania and maintenance, though it requires monitoring 6, 7
• Quetiapine at 400-800 mg daily can serve as both acute treatment and maintenance therapy 5, 7

Critical Pitfalls to Avoid

• Do not continue the SSRI hoping it will help with any underlying depression—this will worsen the mania 1
• Do not rely on lamotrigine alone to control acute mania—it is ineffective for this indication 2, 3
• Do not use benzodiazepines as first-line treatment for the agitation—they worsen fall risk without treating the underlying mania 6
• Do not underdose the antipsychotic—many clinicians use inadequate doses of quetiapine (need 400-800 mg for mania, not 25-100 mg) 5
• Do not discharge without ensuring safety—patients unable to ambulate steadily should be reassessed and likely admitted 6