How should I manage a 68-year-old woman with major depressive disorder on escitalopram (Lexapro) 10 mg who is now experiencing hallucinations?

Management of Hallucinations in a 68-Year-Old Woman with MDD on Escitalopram

Stop the escitalopram immediately and conduct an urgent medical workup to identify reversible causes of delirium, as SSRIs—including escitalopram—can cause delirium with hallucinations in elderly patients, even when previously well-tolerated. 1

Immediate Actions: Rule Out Medical Causes First

Before attributing hallucinations to psychiatric causes, systematically investigate and treat reversible medical triggers that commonly precipitate delirium in older adults:

• Check for infections immediately, particularly urinary tract infections and pneumonia, as these are the most common precipitating factors for acute mental status changes in elderly patients 2, 3
• Assess for metabolic disturbances including hypoxia, dehydration, electrolyte abnormalities, and hyperglycemia 3
• Evaluate for constipation and urinary retention, both of which significantly contribute to behavioral disturbances in patients who cannot verbally communicate discomfort 3
• Review all medications for anticholinergic properties and potential drug interactions that worsen confusion and agitation 3
• Assess pain systematically, as untreated pain is a major contributor to behavioral disturbances in elderly patients 3

The SSRI-Delirium Connection

Escitalopram can cause delirium with hallucinations in elderly patients, even when the medication was previously used without considerable side effects 1. This is a rare but documented complication:

• Only five cases of delirium due to SSRIs as the primary etiologic factor have been published in the last two decades, but the phenomenon is real and clinically significant 1
• SSRIs can cause delirium in aging patients even when previously well-tolerated, suggesting that age-related physiological changes may increase vulnerability 1
• Escitalopram-induced delirium has been specifically documented in elderly patients, with hallucinations as a cardinal feature of the delirious state 1

Discontinuation Strategy

Taper escitalopram gradually over 5-7 days rather than stopping abruptly, as sudden discontinuation can itself precipitate delirium:

• Fluoxetine discontinuation has been documented to cause delirium in a 65-year-old woman with MDD, with delirious pictures developing 2 days after stopping the medication 4
• SSRI discontinuation syndrome symptoms may be attributable to rapid decrease in serotonin availability, and even long-half-life SSRIs can cause withdrawal symptoms in genetically vulnerable individuals 4
• Reduce escitalopram from 10 mg to 5 mg for 3 days, then 2.5 mg for 2-3 days, then discontinue to minimize withdrawal risk while expediting removal of the potential causative agent

Pharmacological Management if Severe Agitation Develops

Reserve antipsychotics only for severe, dangerous agitation with imminent risk of harm after behavioral interventions have failed:

• Use low-dose haloperidol (0.5-1 mg orally or subcutaneously) as first-line for acute severe agitation in elderly patients, with a strict maximum of 5 mg daily 3
• Avoid benzodiazepines as first-line treatment except for alcohol or benzodiazepine withdrawal, as they increase delirium incidence and duration and cause paradoxical agitation in approximately 10% of elderly patients 3
• All antipsychotics increase mortality risk 1.6-1.7 times higher than placebo in elderly patients with dementia, requiring discussion with the patient or surrogate decision maker before initiation 3

Non-Pharmacological Interventions

While conducting the medical workup and tapering escitalopram, implement these evidence-based environmental modifications:

• Ensure adequate lighting and reduce excessive noise to minimize disorientation 3
• Use calm tones, simple one-step commands, and gentle touch for reassurance rather than complex multi-step instructions 3
• Provide frequent reorientation with easily visible calendars, clocks, and familiar objects from home 3
• Maintain consistency of caregivers and minimize relocations to reduce confusion 3
• Ensure at least 30 minutes of sunlight exposure daily and increase supervised mobility 3

Alternative Antidepressant Selection After Resolution

Once the delirium resolves and medical causes are treated, consider restarting antidepressant therapy with a different agent:

• Bupropion may be a safer alternative as it has a different mechanism of action (noradrenergic/dopaminergic rather than serotonergic) and lower risk of delirium 2, 5
• Start bupropion at 37.5 mg every morning in elderly patients, increasing by 37.5 mg every 3 days as tolerated, with a maximum of 150 mg twice daily 5
• Screen for absolute contraindications to bupropion including seizure history, eating disorders, uncontrolled hypertension, and moderate to severe hepatic or renal impairment 5

Critical Monitoring Parameters

• Evaluate daily with in-person examination to assess mental status, orientation, and presence of hallucinations 3
• Monitor for extrapyramidal symptoms, falls, and orthostatic hypotension if antipsychotics are required 3
• Reassess need for any psychotropic medication daily, with the goal of discontinuing as soon as the acute episode resolves 3

Common Pitfalls to Avoid

• Do not assume hallucinations are purely psychiatric without ruling out medical causes—delirium is a medical emergency with twice the mortality if missed 2
• Do not continue escitalopram while investigating if SSRI-induced delirium is suspected, as this delays resolution 1
• Do not use multiple psychotropics simultaneously without first treating reversible medical causes 3
• Do not restart the same SSRI after resolution—choose an alternative antidepressant with a different mechanism of action 5