How should Lexapro (escitalopram) be prescribed to a patient with a history of suicidal thoughts or bipolar disorder?

Prescribing Lexapro (Escitalopram) in Patients with Suicidal Thoughts or Bipolar Disorder

Screen all patients for bipolar disorder before initiating Lexapro, and avoid prescribing it as monotherapy in patients with confirmed or suspected bipolar disorder due to the risk of precipitating mania or mixed episodes. 1

Mandatory Pre-Treatment Screening

• Screen every patient for personal or family history of bipolar disorder, mania, or hypomania before starting escitalopram 1
• This screening must occur prior to initiating treatment, as the FDA label explicitly requires assessment for bipolar disorder risk 1
• Look specifically for: history of manic episodes, family history of bipolar disorder in first-degree relatives, previous antidepressant-induced activation, and rapid mood cycling 2

Contraindications and High-Risk Scenarios

Bipolar Disorder

• SSRIs including escitalopram should be avoided in patients with bipolar disorder due to the risk of precipitating mania 2
• In patients with bipolar disorder, treating a depressive episode with escitalopram may precipitate a mixed or manic episode 1
• The American Academy of Child and Adolescent Psychiatry guidelines indicate that antidepressants may destabilize mood or incite manic episodes in bipolar patients 2
• If a manic episode occurs after starting escitalopram, it is classified as substance-induced per DSM-IV-TR 2

If antidepressant treatment is deemed absolutely necessary in bipolar depression, escitalopram should only be used in combination with a mood stabilizer (lithium, valproate, or atypical antipsychotic), never as monotherapy 2

Suicidal Ideation Risk

• Patients under age 25 have increased risk of suicidal thoughts and behaviors when treated with antidepressants, including escitalopram 1
• The drug-placebo difference shows 14 additional cases of suicidality per 1000 patients treated in those under 18 years, and 5 additional cases per 1000 in patients aged 18-24 1
• Exercise particular caution when prescribing to adolescents with depression and co-morbid suicidal ideation 2

Monitoring Requirements for High-Risk Patients

• Monitor all patients for clinical worsening and emergence of suicidal thoughts, especially during the initial few months of therapy and at times of dosage changes 1
• Counsel family members or caregivers to monitor for behavioral changes and alert the healthcare provider immediately 1
• Reassess symptoms every 2-4 weeks after medication changes 3
• Consider discontinuing escitalopram in patients whose depression persistently worsens or who develop emergent suicidal thoughts or behaviors 1

Dosing Considerations

Standard Dosing

• Start at 10 mg once daily for adults with major depressive disorder 1
• If dose escalation to 20 mg is needed, wait a minimum of one week in adults or three weeks in adolescents 1
• For elderly patients or those with hepatic impairment, use 10 mg/day as the maximum dose 1

Patients with Suicidal Ideation

• Start at the standard 10 mg dose but implement intensive monitoring protocols 1
• Do not escalate doses during periods of acute suicidal ideation
• Ensure close follow-up within 1-2 weeks of initiation 1

Alternative Approaches for Bipolar Depression

If treating bipolar depression, prioritize FDA-approved mood stabilizers over antidepressants:

• Lithium (approved for ages 12+ for acute mania and maintenance) 2
• Atypical antipsychotics (aripiprazole, olanzapine, risperidone, quetiapine) 2
• The combination of olanzapine and fluoxetine is FDA-approved for bipolar depression in adults, not escitalopram 2
• Quetiapine may be particularly effective for motivational symptoms in bipolar disorder 3

Critical Safety Warnings

• Never combine escitalopram with MAOIs—allow at least 14 days between discontinuing an MAOI and starting escitalopram, and vice versa 1
• Monitor for serotonin syndrome, particularly if combining with other serotonergic agents (triptans, tramadol, lithium, fentanyl) 1
• When discontinuing, taper gradually rather than stopping abruptly to avoid discontinuation syndrome 1

When to Avoid Escitalopram Entirely

• Active manic or hypomanic episode 1
• Bipolar disorder without concurrent mood stabilizer coverage 2, 1
• Current MAOI use or within 14 days of MAOI discontinuation 1
• History of antidepressant-induced mania (suggests bipolar diathesis) 4