For many individuals, Lexapro (escitalopram) effectively manages symptoms of generalized anxiety disorder (GAD) and depression. However, it is not a perfect solution for everyone, and some patients find they have only a partial response to treatment, leaving them with lingering or treatment-resistant anxiety. In these cases, a healthcare provider may consider adding a second medication to the regimen to provide more comprehensive relief. The best add-on depends on the patient's specific symptoms, side effects, and overall health profile, underscoring the importance of a personalized approach.
Buspirone (Buspar)
Buspirone, sold under the generic name Buspar, is an anti-anxiety medication that is not a selective serotonin reuptake inhibitor (SSRI) like Lexapro. Instead, it is a partial agonist of the 5-HT1A serotonin receptor, which helps balance serotonin levels in a different way than SSRIs.
How Buspirone works with Lexapro
Buspirone is often added to an SSRI like Lexapro when anxiety symptoms are not fully controlled. While Lexapro boosts the amount of available serotonin, buspirone helps by stimulating certain serotonin receptors. This complementary mechanism can provide broader anti-anxiety effects. Unlike benzodiazepines, buspirone has a low risk of dependence and withdrawal, making it a suitable long-term add-on option. It typically needs to be taken twice a day, and it can take several weeks for its full effects to become apparent.
Bupropion (Wellbutrin)
Bupropion is an atypical antidepressant that works by affecting the neurotransmitters norepinephrine and dopamine, rather than serotonin. This makes it a good candidate for augmenting Lexapro, as it targets different brain pathways.
Combining Bupropion and Lexapro
Adding bupropion to Lexapro is a common strategy, particularly for patients experiencing residual symptoms such as low energy, poor motivation, or fatigue, which are not always fully addressed by SSRIs. This combination is sometimes called 'California Rocket Fuel' when also combined with Mirtazapine, although that is for a different purpose. For some, it can also help counteract sexual side effects that may arise from SSRI use. The different mechanisms of action allow for a more nuanced approach to treatment.
Benzodiazepines (e.g., Xanax, Ativan)
Benzodiazepines are sedative medications that provide rapid, short-term relief for severe anxiety or panic attacks. They work by enhancing the effect of the neurotransmitter GABA, which promotes relaxation.
Short-term use with Lexapro
Because Lexapro can take several weeks to become fully effective, a doctor may prescribe a benzodiazepine for a limited time to help manage acute symptoms during the initial adjustment period. Benzodiazepines are not recommended for long-term use due to the risk of dependence and withdrawal symptoms. Their use is carefully monitored by a healthcare professional.
Hydroxyzine (Vistaril)
Hydroxyzine is an antihistamine that has sedative and anti-anxiety properties. It is often prescribed for short-term relief of anxiety and can also aid with sleep.
Use as a temporary or intermittent add-on
Similar to benzodiazepines, hydroxyzine can be added to a Lexapro regimen temporarily or on an as-needed basis for specific anxiety symptoms. For example, it might be used to manage a sudden spike in anxiety or to help with insomnia related to anxiety. It is not intended for long-term daily use.
Other potential add-ons
- Gabapentin and Pregabalin: These are anticonvulsant medications used off-label for anxiety. They have shown effectiveness in some studies as an add-on therapy for GAD that partially responds to SSRIs. Side effects can include dizziness, sedation, and weight gain.
- Atypical Antipsychotics: Low-dose atypical antipsychotics, such as aripiprazole (Abilify) or quetiapine (Seroquel), can be used to augment an antidepressant for treatment-resistant anxiety. This is typically reserved for more severe or complex cases.
- Mirtazapine (Remeron): An atypical antidepressant that can be added to boost antidepressant effects and aid with sleep and anxiety.
Comparison of Add-On Options for Lexapro
| Add-on Medication | Mechanism | Onset | Primary Use with Lexapro | Common Side Effects |
|---|---|---|---|---|
| Buspirone | Partial 5-HT1A agonist | Weeks | Long-term augmentation for partial response | Dizziness, headache, nausea |
| Bupropion | Norepinephrine & dopamine reuptake inhibitor | Weeks | Address residual symptoms like low energy, motivation | Headache, dry mouth, nausea |
| Benzodiazepines | GABA-A receptor positive modulator | Rapid (minutes-hours) | Short-term relief for acute anxiety, panic attacks | Drowsiness, dependence risk |
| Hydroxyzine | Antihistamine | Rapid (~30 min) | Short-term/intermittent relief, sleep aid | Sedation, dry mouth |
| Gabapentin | Unknown (impacts calcium channels) | Weeks | Off-label augmentation for GAD | Dizziness, sedation, weight gain |
| Aripiprazole (low-dose) | Partial D2 agonist, 5-HT1A partial agonist | Weeks | Augmentation for treatment-resistant cases | Agitation, restlessness, weight gain |
The importance of professional guidance
Deciding on the right add-on medication is a complex process that requires the supervision of a qualified healthcare provider. They will assess your specific needs, review your medical history, and consider potential drug interactions. Starting with a low dose and increasing gradually is a standard practice to minimize side effects. You should never start, stop, or change your medication regimen without discussing it with your doctor first, as improper changes can lead to negative side effects or a worsening of your symptoms.
In addition to medication, a holistic treatment plan often includes psychotherapy, such as cognitive-behavioral therapy (CBT), to address the underlying behavioral aspects of anxiety. Combining these approaches can often lead to the most effective and sustainable results. For more information on anxiety and its treatment, you can visit the Anxiety & Depression Association of America (ADAA) website.
Conclusion
For many individuals with persistent anxiety despite taking Lexapro, adding another medication is a viable and often effective strategy. Options like Buspirone, Bupropion, and short-term use of benzodiazepines or hydroxyzine offer different mechanisms to complement Lexapro's effects. The choice of add-on medication should always be a collaborative decision made with a healthcare provider, considering your specific symptoms, side effect tolerance, and medical history. Augmentation strategies provide hope for achieving more comprehensive relief when initial treatment falls short. Remember that patience and open communication with your doctor are key to finding the right balance for your mental health needs.
