What medication can be taken with Lexapro (escitalopram) for a patient with high anxiety?

Augmentation Medication for High Anxiety with Lexapro

Buspirone is the safest and most evidence-based medication to add to Lexapro (escitalopram) for high anxiety, starting at 5 mg twice daily and titrating up to 10-15 mg twice daily over 2-4 weeks. 1

Primary Recommendation: Buspirone

The American Academy of Child and Adolescent Psychiatry recommends buspirone as first-line augmentation for anxiety disorders in patients taking escitalopram, with a maximum dose of 20 mg three times daily if needed. 1

Dosing Protocol

• Start buspirone at 5 mg twice daily 1, 2
• Increase by 5 mg every 3-5 days as tolerated 2
• Target dose: 10-15 mg twice daily 1, 2
• Maximum dose: 20 mg three times daily 1

Critical Timing Consideration

• Buspirone requires 2-4 weeks to achieve full anxiolytic effects—patients must be counseled about this delayed onset to prevent premature discontinuation. 1
• The combination avoids risks of combining multiple serotonergic agents while providing complementary mechanisms of action 1

Alternative: PRN Benzodiazepines for Breakthrough Anxiety

For acute anxiety episodes only, low-dose lorazepam (0.25-0.5 mg) can be used cautiously and infrequently while buspirone takes effect. 1

Strict Usage Parameters

• Maximum single dose: 0.25-0.5 mg lorazepam 1
• Maximum daily dose: 2 mg lorazepam equivalent 1
• Frequency must be strictly limited to no more than 2-3 times weekly to minimize tolerance and dependence risk. 1
• Provides rapid anxiolytic effects with lower sedation risk at these doses 1

Critical Safety Warnings

• When combining benzodiazepines with SSRIs, start at the lowest effective dose and monitor closely, especially in the first 24-48 hours. 1
• Benzodiazepines carry approximately 10% risk of paradoxical agitation 1
• Abrupt benzodiazepine withdrawal can cause rebound anxiety, hallucinations, seizures, and rarely death. 1, 2
• Regular use leads to tolerance and dependence 1

Clinical Algorithm

Follow this decision pathway when adding anxiety medication to escitalopram: 1

1. First-line: Start buspirone 5 mg twice daily 1
2. If breakthrough anxiety during buspirone titration: Consider low-dose PRN lorazepam (0.25-0.5 mg, maximum 2-3 times weekly) 1
3. At 4 weeks: Assess buspirone efficacy before declaring treatment failure 2
4. If buspirone fails after 4-6 weeks: Increase escitalopram dose (if not already at maximum) 2
5. Alternative second-line options: Consider pregabalin, gabapentin, or SNRIs like venlafaxine 2

Monitoring Requirements

• Assess anxiety symptoms weekly during the first month of augmentation. 2
• Monitor for signs of benzodiazepine tolerance or dependence if using PRN lorazepam 1
• Screen for emergence of depression or suicidal ideation during medication changes 2
• Regular monitoring is essential to assess ongoing need versus potential for discontinuation 1

Non-Pharmacological Adjuncts

Cognitive-behavioral therapy should be strongly considered as an adjunctive intervention, with strong evidence for enhanced outcomes when combined with pharmacotherapy. 1

• Psychoeducation about symptoms, treatment options, and medication adherence improves long-term outcomes 1
• CBT increases success rates during medication transitions 2

Common Pitfalls to Avoid

• Do not use benzodiazepines as scheduled daily medication—this rapidly leads to tolerance and dependence. 1
• Do not discontinue buspirone before 4 weeks—premature discontinuation due to delayed onset is common. 1, 2
• Do not combine escitalopram with MAOIs or pimozide due to serious cardiac and serotonergic risks. 3
• Avoid alcohol while taking escitalopram 3

Escitalopram's Baseline Anxiolytic Properties

Escitalopram itself has well-established efficacy for generalized anxiety disorder, with FDA approval for this indication 3. Multiple studies demonstrate significant improvement in anxiety symptoms within 1-2 weeks of starting escitalopram 4, 5, 6. If anxiety remains high despite adequate escitalopram dosing (10-20 mg daily) and duration (at least 4-6 weeks), augmentation with buspirone is appropriate 1, 2.