Should Lexapro Be Restarted in This Patient?
Yes, Lexapro (escitalopram) should be restarted and continued alongside the newly initiated Abilify (aripiprazole) 5mg. This patient requires combination therapy with both an antidepressant and an antipsychotic given the presentation of depression with psychotic features (auditory hallucinations).
Rationale for Combination Therapy
The presence of auditory hallucinations in the context of major depression indicates psychotic depression, which requires treatment with both an antidepressant and an antipsychotic. 1
- Escitalopram combined with aripiprazole has demonstrated efficacy specifically for psychotic major depressive disorder, with a 62.5% response rate and 50% remission rate in clinical trials 1
- Monotherapy with either agent alone is insufficient for psychotic depression—the combination addresses both the depressive symptoms and psychotic features 1
- The patient has only been on Lexapro for 2 weeks, which is insufficient time to assess antidepressant efficacy, as therapeutic effects typically require 4-6 weeks 2
Timing and Treatment Duration Considerations
Discontinuing Lexapro prematurely after only 2 weeks would be inappropriate and could worsen outcomes:
- Early discontinuation of antidepressants (after just one prescription) is associated with poor long-term outcomes, with only 24.1% of patients restarting treatment within 9 months and only 29.3% of those who restart completing an adequate treatment course 3
- Antidepressants require continued use for 4-6 months minimum to prevent relapse in major depressive disorder 4
- Abrupt discontinuation can precipitate antidepressant discontinuation syndrome with symptoms including dysphoric mood, irritability, agitation, dizziness, sensory disturbances, anxiety, and insomnia 4, 5
Safety Profile of the Combination
The escitalopram-aripiprazole combination has a favorable safety profile when properly monitored:
- The primary adverse effect is akathisia, which occurred in 62.5% of patients in one study but was manageable with dose adjustment or propranolol treatment 1
- Escitalopram has minimal drug-drug interaction potential compared to other SSRIs, as it has the least effect on CYP450 isoenzymes 6
- Aripiprazole as a third-generation antipsychotic has lower risk of extrapyramidal symptoms compared to first-generation antipsychotics 6
Critical Monitoring Requirements
Monitor closely for serotonin syndrome given the combination of serotonergic agents:
- Watch for mental status changes (agitation, confusion), autonomic instability (tachycardia, diaphoresis), and neuromuscular symptoms (tremor, hyperreflexia) 4
- These symptoms typically emerge within 24-48 hours of combining serotonergic medications 6
Monitor for suicidal ideation intensively during the initial treatment period:
- The patient already presents with suicidal ideation, requiring heightened vigilance 4
- Antidepressants carry a black box warning for increased suicidal thoughts and behaviors, particularly in the first few months of treatment 4
- Weekly or biweekly follow-up is essential during the first 4-8 weeks 4
Assess for akathisia and extrapyramidal symptoms:
- Use standardized scales (Barnes Akathisia Scale, Simpson Angus Scale) to objectively measure these effects 1
- Have propranolol available for akathisia management if needed 1
Common Pitfalls to Avoid
- Do not discontinue the antidepressant when adding an antipsychotic for psychotic depression—both medications are necessary to address different symptom domains 1
- Do not expect rapid response—allow at least 4-6 weeks before assessing full therapeutic effect of the combination 2
- Do not abruptly stop escitalopram if switching medications—taper over weeks to months to minimize discontinuation syndrome 4, 5
- Do not assume the auditory hallucinations are solely from depression—they may represent psychotic features requiring ongoing antipsychotic treatment even after mood symptoms improve 1