Can Lexapro (escitalopram) be discontinued in a patient with a new diagnosis of bipolar disorder who has only received 2 doses, started yesterday, and is also taking Vraylar (cariprazine)?

Discontinuing Lexapro After 2 Doses in Newly Diagnosed Bipolar Disorder

Yes, discontinue Lexapro immediately—antidepressant monotherapy or inappropriate combination in bipolar disorder carries significant risk of mood destabilization, mania induction, and rapid cycling, and after only 2 doses, abrupt discontinuation poses minimal withdrawal risk. 1

Rationale for Immediate Discontinuation

The American Academy of Child and Adolescent Psychiatry explicitly recommends against antidepressant monotherapy or inappropriate combination in bipolar disorder due to risk of mood destabilization, mania induction, and rapid cycling. 2, 1 This is a critical safety concern that supersedes typical discontinuation protocols.

Why 2 Doses Allows Safe Abrupt Discontinuation

• After only 2 doses started yesterday, the patient has minimal drug exposure and has not reached steady-state levels, making withdrawal symptoms extremely unlikely. 3
• The FDA label for escitalopram notes that discontinuation symptoms typically occur after prolonged use, not after 1-2 doses. 4
• Gradual tapering is recommended to avoid withdrawal symptoms (dysphoric mood, irritability, agitation, dizziness, sensory disturbances) when discontinuing SSRIs, but this applies to patients on established therapy, not those who just started. 3, 4

Specific Risks of Continuing Lexapro in Bipolar Disorder

• Escitalopram can precipitate mixed/manic episodes in patients with bipolar disorder, with the FDA label specifically warning about activation of mania/hypomania. 4
• Treatment-emergent mania can occur in a dose-related manner with escitalopram, sometimes emerging within 1 month of treatment initiation or dose increases. 5
• Even withdrawal from escitalopram has been documented to trigger manic states in some patients, though this typically occurs after established use, not after 2 doses. 6

Current Medication Strategy with Vraylar

• Cariprazine (Vraylar) monotherapy is an evidence-based, FDA-approved approach for bipolar depression and should be continued for at least 6-8 weeks at therapeutic dose before concluding effectiveness. 1, 7, 8
• Cariprazine has demonstrated efficacy for bipolar depression with response rates of 46.3% vs 35.9% for placebo (NNT 10), and is specifically approved for this indication. 7
• The patient should continue Vraylar as prescribed while monitoring for treatment response over the next 6-8 weeks. 1

Monitoring After Lexapro Discontinuation

• Monitor for any mood destabilization or emergence of manic/hypomanic symptoms in the days following Lexapro discontinuation, though risk is minimal given brief exposure. 1, 4
• Schedule follow-up within 1-2 weeks to reassess depressive symptoms and verify that mood remains stable on Vraylar monotherapy. 2
• Use standardized rating scales to objectively track depressive symptoms and functional impairment during this period. 1

If Additional Treatment Is Needed Later

• If depressive symptoms persist after a full 6-8 week trial of Vraylar at therapeutic dose, lamotrigine is the evidence-based choice for augmentation in bipolar depression, particularly effective for preventing depressive episodes. 1
• Cognitive-behavioral therapy should be initiated as adjunctive non-pharmacological treatment, which has strong evidence for both depressive and anxiety components of bipolar disorder. 2, 1
• Never restart Lexapro or add any other SSRI monotherapy, as this significantly increases risk of mood destabilization and rapid cycling in bipolar disorder. 1

Common Pitfall to Avoid

• Do not continue the antidepressant "just to taper it" when only 2 doses have been given—this unnecessarily prolongs exposure to a contraindicated medication in bipolar disorder and increases the risk of mood destabilization. 1, 4