What is the process for switching an adult patient with a history of depression or anxiety from Lexapro (escitalopram) to vilazodone?

Switching from Lexapro (Escitalopram) to Vilazodone

When switching from escitalopram to vilazodone, perform a direct cross-taper without a washout period, starting vilazodone at 10 mg daily while tapering escitalopram over 1-2 weeks to minimize discontinuation symptoms.

Switching Strategy

Direct Cross-Taper Approach

The preferred method is a direct switch with overlapping taper rather than abrupt discontinuation. 1 This approach minimizes the risk of SSRI discontinuation syndrome while initiating the new medication.

Specific Tapering Protocol

Escitalopram Taper:

• If on escitalopram 20 mg daily: reduce to 10 mg daily for 7 days, then discontinue 1
• If on escitalopram 10 mg daily: reduce to 5 mg daily for 7 days, then discontinue 1
• A gradual reduction is recommended whenever possible to avoid discontinuation reactions 1

Vilazodone Initiation (concurrent with escitalopram taper):

• Start vilazodone 10 mg once daily with food for 7 days 1
• Increase to 20 mg once daily with food after 7 days 1
• May increase to target dose of 40 mg once daily after an additional 7 days at 20 mg 1
• Critical: Vilazodone must be taken with food for optimal bioavailability 1, 2

Important Safety Considerations

No MAOI Washout Required

Unlike switching to or from MAOIs, no washout period is required when switching between SSRIs (escitalopram and vilazodone). 1 The 14-day washout requirement only applies to MAOI transitions. 1

Serotonin Syndrome Risk

Monitor closely for serotonin syndrome during the overlap period, though risk is relatively low with this switch since both are serotonergic agents with similar mechanisms. 1 Watch for tremor, diarrhea, delirium, neuromuscular rigidity, and hyperthermia. 3

Expected Timeline for Symptom Improvement

• Vilazodone shows improvement in depressive symptoms within 1 week of initiating therapy 4
• Clinically significant improvement typically occurs by week 2 5
• Maximum therapeutic effect is observed at 4-6 weeks 4
• This rapid onset may help bridge any gap during the transition 5

Monitoring During Transition

Adverse Effects to Anticipate

The most common adverse effects with vilazodone are diarrhea (most common), nausea, vomiting, and insomnia. 1, 4, 5, 2 These typically emerge within the first few weeks and are often self-limited, resolving in 4-5 days. 4

Advantages of vilazodone over traditional SSRIs:

• Limited adverse effects on sexual function 5
• Minimal impact on body weight 5
• These benefits may improve adherence compared to escitalopram 5

Clinical Assessment Points

Monitor at:

• Week 1: Assess for discontinuation symptoms from escitalopram and early vilazodone tolerability 1
• Week 2: Evaluate early therapeutic response and adjust dose to 20 mg if tolerated 1
• Week 4: Consider increasing to target dose of 40 mg if needed 1
• Week 6-8: Assess full therapeutic response 5

Common Pitfalls to Avoid

1. Not taking vilazodone with food: This significantly reduces bioavailability and effectiveness 2
2. Abrupt escitalopram discontinuation: Always taper gradually to minimize discontinuation syndrome 1
3. Rushing vilazodone titration: Allow 7 days between dose increases 1
4. Inadequate monitoring for suicidal ideation: Particularly important in patients under age 25 during any antidepressant transition 1