Can Lexapro (Escitalopram) Cause Hallucinations?
Yes, Lexapro (escitalopram) can cause hallucinations, though this is a rare but serious adverse effect that requires immediate discontinuation of the medication.
Mechanism and Clinical Context
Hallucinations associated with escitalopram typically occur as part of serotonin syndrome, a potentially life-threatening condition that develops when serotonergic activity becomes excessive 1. The FDA labeling explicitly warns that serotonin syndrome symptoms may include mental status changes such as agitation, hallucinations, delirium, and coma, particularly when escitalopram is combined with other serotonergic drugs 1.
Risk Factors for Hallucinations
High-risk scenarios include:
- Drug combinations: Concurrent use with MAOIs, triptans, tricyclic antidepressants, fentanyl, lithium, tramadol, buspirone, amphetamines, or St. John's Wort significantly increases risk 1
- Underlying conditions: Patients with pre-existing psychiatric conditions, neurodegenerative disorders, or renal/hepatic impairment are at elevated risk 2
- Recent medication changes: Hallucinations can develop shortly after starting escitalopram or after dose adjustments 3, 4
Clinical Presentation
Hallucinations from escitalopram may present as:
- Visual or auditory hallucinations occurring as isolated symptoms 1
- Part of serotonin syndrome: accompanied by autonomic instability (tachycardia, labile blood pressure, hyperthermia), neuromuscular symptoms (tremor, rigidity, hyperreflexia), and gastrointestinal symptoms 1
- Acute psychosis: with delusions, confusion, agitation, and disorientation 1, 3
Immediate Management
When hallucinations occur:
- Discontinue escitalopram immediately 1, 3, 2
- Discontinue all concomitant serotonergic agents if serotonin syndrome is suspected 1
- Initiate supportive symptomatic treatment for serotonin syndrome features 1
- Monitor closely: Most cases resolve quickly after drug cessation, typically within days to weeks 3, 2
Important Caveats
Do not confuse with therapeutic use: Paradoxically, escitalopram has been successfully used to treat hallucinations in specific contexts like Charles Bonnet syndrome (visual hallucinations from vision impairment) and obsessive-compulsive-related musical hallucinations in elderly patients with hearing loss 5, 6. However, these represent distinct clinical scenarios where hallucinations stem from sensory deprivation, not drug toxicity.
Post-marketing surveillance has documented multiple psychiatric adverse effects including hallucinations (both visual and auditory), acute psychosis, delusions, and delirium as recognized complications of escitalopram therapy 1.
Clinical Decision Point
If a patient on escitalopram develops hallucinations:
- Stop the medication immediately
- Rule out serotonin syndrome by assessing for autonomic instability and neuromuscular hyperactivity
- Review all concurrent medications for serotonergic interactions
- Consider alternative antidepressant therapy only after complete symptom resolution, avoiding agents with similar risk profiles 2