Is it common for a 20-year-old autistic female, taking Lexapro (escitalopram) and Tandospirone (sedative anxiolytic), to experience waves of sadness, depression, and mood fluctuations during the luteal phase, and can Selective Serotonin Reuptake Inhibitor (SSRI) intake exacerbate mood and anxiety symptoms?

From the Guidelines

It is common for a 20-year-old autistic woman on Lexapro (escitalopram) and tandospirone to experience waves of sadness, depression, and mood fluctuations during her luteal phase, which can be exacerbated by the initial effects of SSRI intake. The worsening of mood or anxiety after starting an SSRI like Lexapro is a recognized phenomenon, as SSRIs initially increase serotonin availability in the synaptic cleft, but before the brain adapts to these changes (which takes 2-6 weeks), some people experience increased anxiety or agitation 1. In autistic individuals, this sensitivity may be heightened due to differences in neurotransmitter systems, as serotonergic function plays a key role in modulating fear, worry, and stress, and SSRIs work by inhibiting the presynaptic reuptake of serotonin, thereby increasing its availability at the synaptic cleft 1.

Key Factors Influencing Mood Fluctuations

• Hormonal fluctuations during the luteal phase, where estrogen and progesterone levels change dramatically, can affect how medications work by influencing serotonin receptor sensitivity and potentially reducing the effectiveness of SSRIs temporarily.
• The combination of autism, which often involves altered neurotransmitter function, hormonal changes during the luteal phase, and the initial adjustment period to SSRIs creates a biological perfect storm for mood fluctuations.
• The primary mechanism of SSRIs, including Lexapro, is deemed sufficiently similar across individual medications to warrant extension of the findings to the medication class, despite variations in pharmacokinetics and pharmacodynamics 1.

Biological and Psychiatric Mechanisms

The initial increase in serotonin availability caused by SSRIs can lead to a downregulation of inhibitory serotonin autoreceptors, which eventually heightens the serotonergic neuronal firing rate, increasing serotonin release 1. This multistep process is hypothesized to be related to the delay in onset of the SSRI treatment effect. In the context of autism and hormonal fluctuations, this process can be particularly complex, leading to the observed mood fluctuations and worsening of anxiety in some cases.

From the FDA Drug Label

Watch for these changes and call your healthcare provider right away if you notice: • New or sudden changes in mood, behavior, actions, thoughts, or feelings, especially if severe. • Pay particular attention to such changes when Escitalopram tablets are started or when the dose is changed

Call your healthcare provider right away if you have any of the following symptoms, or call 911 if an emergency, especially if they are new, worse, or worry you: • attempts to commit suicide • acting on dangerous impulses • acting aggressive or violent • thoughts about suicide or dying • new or worse depression • new or worse anxiety or panic attacks • feeling agitated, restless, angry or irritable • trouble sleeping • an increase in activity or talking more than what is normal for you • other unusual changes in behavior or mood

It is possible for a 20-year-old autistic woman taking Lexapro (escitalopram) and tandospirone to experience mood fluctuations, including sadness and depression, during her luteal phase. The FDA drug label for escitalopram warns of potential mood changes, including new or worse depression and new or worse anxiety.

• Mood changes can occur, especially when starting or changing the dose of escitalopram.
• Hormonal fluctuations during the luteal phase may contribute to mood changes.
• Autism and anxiety can also impact mood stability. However, the exact mechanism behind worsening mood or anxiety after SSRI intake is not explicitly stated in the provided drug labels. It is essential to monitor mood changes and report any concerns to the healthcare provider. Key points to consider:
• Mood fluctuations can occur with escitalopram treatment.
• Hormonal changes during the luteal phase may contribute to mood changes.
• Autism and anxiety can impact mood stability.
• Regular monitoring and open communication with the healthcare provider are crucial. 2 2 2

From the Research

Hormonal Influences on Mood

• The luteal phase is associated with increased progesterone levels, which can contribute to mood fluctuations in some individuals 3.
• Hormonal changes during the menstrual cycle can affect serotonin levels, potentially influencing mood and anxiety symptoms 3.

SSRI Effects on Mood and Anxiety

• Selective serotonin reuptake inhibitors (SSRIs) can have varying effects on individuals with autism spectrum disorder (ASD), with some studies suggesting improvements in anxiety and depressive symptoms 4, 5.
• However, other studies have reported that SSRIs can exacerbate anxiety and mood symptoms in some individuals with ASD, particularly during the initial treatment phase 4, 5.
• The mechanism behind this phenomenon is not fully understood but may be related to the complex interplay between serotonin, dopamine, and other neurotransmitters in the brain 6.

Autism Spectrum Disorder and SSRI Treatment

• Individuals with ASD may exhibit abnormal brain activation patterns during executive functioning tasks, which can be influenced by SSRI treatment 6.
• Citalopram, an SSRI, has been shown to "normalize" atypical brain activation in individuals with ASD during executive functioning tasks, although the long-term effects of this treatment are unclear 6.
• The effectiveness of SSRIs in treating anxiety and depressive symptoms in individuals with ASD may depend on various factors, including the specific medication, dosage, and individual characteristics 4, 5.

Anxiety and Depression Comorbidity

• Comorbid anxiety and depression, also known as anxious depression, is a common syndrome that can have distinct neurobiological profiles and treatment responses compared to non-anxious depression 3.
• Individuals with anxious depression may be more likely to experience severe depressive symptoms, suicidal ideation, and treatment resistance, highlighting the need for tailored treatment approaches 3.