Psychiatric Follow-Up Note
Patient Information
Chief Complaint: Psychiatric follow-up during medication transition from sertraline (Zoloft) to escitalopram (Lexapro)
History of Present Illness
Patient discontinued sertraline due to night sweats and partial response with emotional numbing. Completed taper and initiated escitalopram 5 mg one week ago (last Monday). Reports mood was more stable and consistently positive on sertraline despite side effects. Since medication switch, experiencing mood fluctuations ("some days okay, others harder"), increased morning anxiety ("freaking out" without clear trigger), and sleep fragmentation (waking every ~2 hours, going to bed late, waking early). New onset crying spells since discontinuation of sertraline, which did not occur while on that medication. Currently engaged in therapy addressing self-doubt and trauma processing.
Positive symptoms: Morning anxiety worse than evening, sleep disturbances, crying spells, social isolation, anhedonia (stopped enjoying hiking), holiday-related stress
Negative symptoms: Denies panic attacks, suicidal ideation, self-harm thoughts, hallucinations, substance use
Medication adherence: Reports taking Lexapro consistently
Assessment and Clinical Reasoning
The current escitalopram dose of 5 mg is subtherapeutic and should be increased to 10 mg daily immediately, as this represents the standard starting therapeutic dose for anxiety and depression. 1, 2
Rationale for Dose Increase
Escitalopram 10-20 mg daily is the evidence-based therapeutic range for both major depressive disorder and generalized anxiety disorder, with 5 mg representing only an initial titration dose 1, 3, 4
The patient's worsening symptoms (mood fluctuations, increased morning anxiety, sleep disturbances, crying spells) likely reflect both inadequate escitalopram dosing and discontinuation effects from sertraline cessation 2
Escitalopram demonstrates superior efficacy for sleep problems in depression and anxiety compared to placebo and other SSRIs/SNRIs, but requires adequate dosing (10-20 mg) to achieve this benefit 5
Addressing Discontinuation Syndrome
The patient's symptoms (mood lability, crying spells, anxiety, sleep disturbances) are consistent with SSRI discontinuation syndrome, which typically resolves within 1-2 weeks but can persist up to 4 weeks 1, 2
Gradual dose reduction is recommended when discontinuing SSRIs to minimize discontinuation symptoms; however, since the taper is complete, the focus should shift to achieving therapeutic escitalopram levels 2
Sleep Management Strategy
Escitalopram at therapeutic doses (10-20 mg) significantly improves sleep problems in patients with depression and anxiety, particularly in those with baseline sleep disturbances 5
If insomnia persists after 2-4 weeks at escitalopram 10 mg, consider adding eszopiclone 3 mg nightly, which has demonstrated efficacy when coadministered with escitalopram for comorbid insomnia and anxiety, with improved sleep, daytime functioning, and faster onset of anxiolytic response 6
Avoid benzodiazepines for routine sleep management due to risk of dependence and potential to worsen depression 1
Timeline for Response
Allow 2-4 weeks at escitalopram 10 mg to assess full therapeutic response before considering further dose adjustment to 20 mg 7
Escitalopram demonstrates rapid onset of symptom improvement, with some parameters improving within 1-2 weeks, and shows earlier separation from placebo compared to other SSRIs 4
The patient should expect gradual improvement in mood stability, anxiety, and sleep over the next 2-4 weeks as therapeutic levels are achieved 3, 4
Safety Monitoring
Monitor closely for serotonin syndrome (agitation, confusion, tachycardia, tremor, rigidity, hyperthermia), particularly given recent sertraline exposure, though risk is low with SSRI monotherapy 2
Screen for activation of mania/hypomania given mood fluctuations, though risk is minimal (0.1% in clinical trials) 2
Monitor for hyponatremia, particularly if patient develops confusion, headache, or worsening symptoms 2
Assess for suicidal ideation at each visit, especially during the initial treatment period and dose changes 2
Therapy Integration
Continue cognitive behavioral therapy (CBT), as combination therapy demonstrates superior outcomes compared to medication alone, particularly for anxiety comorbidities 7
Therapy should address identified issues: self-doubt, trauma processing, social isolation, anhedonia, and holiday-related stress
Plan
Medication Management
- Increase escitalopram to 10 mg daily immediately (standard therapeutic dose) 1, 2, 3
- Continue this dose for minimum 2-4 weeks to assess response 7
- If inadequate response after 4 weeks at 10 mg, increase to 20 mg daily 1, 2
- If insomnia persists after 2 weeks at therapeutic escitalopram dose, consider adding eszopiclone 3 mg nightly 6
Follow-Up
Schedule follow-up in 2 weeks to assess:
- Mood stability and anxiety levels
- Sleep quality and pattern
- Resolution of discontinuation symptoms
- Medication tolerability
- Suicidal ideation screening
If symptoms improve but remain suboptimal at 4 weeks, increase to escitalopram 20 mg daily 1, 2
Non-Pharmacological Interventions
- Continue weekly psychotherapy focusing on CBT techniques 7
- Encourage gradual re-engagement with previously enjoyed activities (hiking)
- Address social isolation and holiday planning in therapy sessions
Patient Education
- Explained that current 5 mg dose is below therapeutic range
- Discussed expected timeline for improvement (1-4 weeks)
- Reviewed potential side effects: nausea (typically mild and transient), possible initial insomnia, sexual side effects 2, 4
- Emphasized importance of medication adherence
- Instructed to contact immediately if experiencing worsening depression, suicidal thoughts, or severe agitation 2