Management of New-Onset Hallucinations in a 68-Year-Old Woman After Starting Escitalopram
The hallucinations are most likely an adverse drug effect of escitalopram, and the appropriate management is to discontinue escitalopram entirely and avoid restarting it, as the patient has already demonstrated a serious neuropsychiatric reaction that can recur or worsen with re-exposure.
Understanding the Clinical Picture
Escitalopram as the Likely Culprit
Escitalopram can cause serious neuropsychiatric side effects including hallucinations, agitation, and changes in mental status, particularly when treatment is initiated or the dose is changed, and these effects warrant immediate discontinuation 1.
The FDA Medication Guide for escitalopram explicitly warns about "hallucinations" as a manifestation of serotonin syndrome, a potentially life-threatening condition that can occur with SSRI use 1.
In elderly patients, escitalopram has been associated with new-onset hallucinations, and case reports document that re-administration after a brief interruption can trigger severe reactions including convulsions, impaired consciousness, and myoclonus—especially in older adults or those in poor physical condition 2.
The temporal relationship is highly suggestive: hallucinations began after starting escitalopram and have persisted despite weaning off the medication, indicating a drug-induced phenomenon that may take time to fully resolve 1, 2.
Why Aripiprazole (Abilify) Has Not Helped
Aripiprazole 5 mg is being used to treat a symptom (hallucinations) rather than addressing the underlying cause (escitalopram toxicity), and antipsychotics are not the appropriate first-line management for drug-induced hallucinations 1.
Adding an antipsychotic does not reverse serotonergic toxicity; the primary intervention is discontinuation of the offending agent and supportive care 1, 2.
Immediate Management Steps
1. Confirm Complete Discontinuation of Escitalopram
Verify that escitalopram has been fully stopped and determine how long ago it was discontinued, as SSRIs can have lingering effects due to their half-lives 1.
Do not restart escitalopram under any circumstances, as re-exposure in elderly patients—even after a short interruption—has resulted in severe serotonin syndrome with convulsions, fever, and altered consciousness 2.
2. Assess for Serotonin Syndrome
Evaluate for signs of serotonin syndrome, which can present with hallucinations along with agitation, confusion, muscle twitching (myoclonus), hyperreflexia, fever, sweating, racing heartbeat, nausea, vomiting, or diarrhea 1.
Check vital signs and perform a neurological examination looking specifically for hyperreflexia, clonus (especially inducible clonus at the ankle), muscle rigidity, and tremor 1.
If serotonin syndrome is suspected, initiate supportive care immediately: discontinue all serotonergic agents, provide intravenous fluids, control agitation with benzodiazepines (not antipsychotics), and consider hospital admission for monitoring 1, 2.
3. Rule Out Other Causes of Hallucinations
Although UTI has been ruled out, reassess for other metabolic or infectious causes: check complete metabolic panel (sodium, calcium, glucose, renal function), thyroid function, vitamin B12, and consider repeat urinalysis if any new urinary symptoms develop 3.
Evaluate for delirium using a validated tool such as the Confusion Assessment Method (CAM), as delirium can present with hallucinations and may be triggered by multiple factors including medications, infections, or metabolic disturbances 3.
Review all current medications for other potential contributors: benzodiazepines, anticholinergics, corticosteroids, opioids, and other psychoactive drugs can all cause hallucinations in elderly patients 3.
Assess for Charles Bonnet syndrome if the patient has any degree of vision impairment (reduced acuity, contrast sensitivity, or visual field loss), as this can cause vivid visual hallucinations in visually impaired individuals 3.
Definitive Management Plan
Discontinue Aripiprazole
Taper and discontinue aripiprazole once escitalopram has been fully cleared (typically 1–2 weeks after stopping), as the hallucinations should resolve without the need for ongoing antipsychotic treatment if they were drug-induced 1, 2.
Antipsychotics are not indicated for drug-induced hallucinations and carry their own risks in elderly patients, including extrapyramidal symptoms, falls, and increased mortality 3.
Monitor for Resolution
Hallucinations from escitalopram toxicity typically resolve within 1–3 weeks after complete discontinuation, though recovery may take longer in elderly patients 2.
Schedule close follow-up (within 48–72 hours initially, then weekly) to monitor symptom resolution and assess for any new or worsening neuropsychiatric symptoms 1.
Address the Underlying Depression
If the patient requires ongoing treatment for depression, consider non-serotonergic alternatives such as bupropion or mirtazapine, which have different mechanisms of action and lower risk of serotonergic toxicity 4.
Avoid all SSRIs and SNRIs in this patient, as she has demonstrated a serious adverse reaction to escitalopram and cross-reactivity with other serotonergic agents is possible 1, 2.
Consider non-pharmacological interventions including psychotherapy (cognitive-behavioral therapy or interpersonal therapy), which are effective for depression in older adults and carry no risk of drug-induced hallucinations 5.
Critical Pitfalls to Avoid
Do Not Restart Escitalopram
Re-administration of SSRIs after a brief interruption is particularly dangerous in elderly patients, as documented cases show severe serotonin syndrome with convulsions, high fever, and impaired consciousness upon rechallenge 2.
Even if the patient's depression worsens, escitalopram is contraindicated given her prior reaction; alternative antidepressants with different mechanisms must be used 1, 2.
Do Not Assume Hallucinations Are Primary Psychosis
New-onset hallucinations in a 68-year-old woman with recent medication changes are drug-induced until proven otherwise, and treating with antipsychotics without addressing the underlying cause is inappropriate 3, 1.
Primary psychotic disorders rarely present for the first time in late life; secondary causes (medications, metabolic disturbances, neurological conditions) must be systematically excluded 3.
Do Not Overlook Delirium
Delirium can present with hallucinations and is common in elderly patients, particularly in the setting of medication changes, infections, or metabolic disturbances 3.
Use a validated screening tool (CAM or CAM-ICU) to assess for delirium, as it requires specific management including identifying and treating the underlying cause, optimizing the environment, and avoiding sedating medications 3.
Patient and Family Education
Explain the Likely Cause
Inform the patient and family that the hallucinations are most likely a side effect of escitalopram and should resolve now that the medication has been stopped 1, 2.
Reassure them that this is a recognized adverse reaction and does not indicate a primary psychiatric disorder or dementia 1.
Provide Safety Guidance
Advise the patient to seek immediate medical attention if she develops fever, muscle rigidity, severe confusion, seizures, or inability to care for herself, as these may indicate serotonin syndrome or other serious complications 1.
Ensure a safe home environment: remove fall hazards, provide adequate lighting, and consider supervision if hallucinations are distressing or impairing judgment 3.
Set Expectations for Recovery
Explain that full resolution may take 1–3 weeks after stopping escitalopram, and symptoms may fluctuate during this period 2.
Schedule regular follow-up to monitor progress and adjust the treatment plan as needed 1.
Summary Algorithm
- Confirm escitalopram is fully discontinued → Do not restart under any circumstances 1, 2.
- Assess for serotonin syndrome → Check for hyperreflexia, clonus, fever, agitation; initiate supportive care if present 1.
- Rule out other causes → Metabolic panel, delirium screening (CAM), medication review, vision assessment 3.
- Taper aripiprazole → Discontinue once escitalopram is cleared (1–2 weeks) 3.
- Monitor for resolution → Expect improvement within 1–3 weeks; schedule close follow-up 2.
- Address depression with non-serotonergic alternatives → Consider bupropion, mirtazapine, or psychotherapy 4, 5.
- Educate patient/family → Explain drug-induced cause, provide safety guidance, set recovery expectations 1, 2.