escitalopram
Last reviewed 2026-02-12
Reviewed by PsychMed Editorial Team.
Brands: Lexapro
Sources updated 2026 • 4 references
General Information
Escitalopram (Lexapro) is an SSRI commonly used for major depressive disorder and generalized anxiety disorder with a favorable tolerability profile.
Preferred over citalopram for lower QT risk at therapeutic doses and minimal drug interactions.
Clinical response often begins within 2–4 weeks (sometimes longer for anxiety symptoms); expectations and follow-up planning can reduce premature discontinuation when early side effects are manageable.
The compare view and the escitalopram evidence feed can support switching plans, QT considerations, and augmentation strategies; mania-prevention planning can be coordinated via the bipolar disorder hub.
U.S. approvals
- Major depressive disorder (2002)
- Generalized anxiety disorder (2003)
Formulations & strengths
- Tablets: 5 mg, 10 mg, 20 mg; oral solution 5 mg/5 mL.
Generic availability
- Generic formulations available since 2012.
Hyponatremia and serotonin syndrome are key safety considerations; otherwise escitalopram is generally well tolerated with once-daily dosing. Coordination with the bipolar disorder hub can support mania-prevention planning in bipolar-spectrum illness.
View labelExactMechanism of Action
Refer to the Glossary entry on Neurotransmitters for background on receptor systems involved in serious mental illness.
Highly selective serotonin reuptake inhibitor (selective SERT blockade) with negligible affinity for other receptors.
- Selective SERT inhibitor.
Metabolism and Pharmacokinetics
- Tmax 3–5 h; half-life ~27–32 h.
- Metabolized via CYP2C19, CYP2D6, CYP3A4 to less active metabolites; eliminated renally as metabolites.
- Hepatic impairment can increase exposure; lower starting doses and slower titration are commonly used when tolerability limits continuation.
- CYP2C19 poor metabolizers can have higher exposure; dose caps and careful monitoring help reduce adverse effects.
Dosing and Administration
- Typical adult start is 10 mg once daily; may increase to 20 mg/day after ≥1 week if needed and tolerated.
- Elderly/CYP2C19 poor metabolizers: lower starting dose (often 5 mg) and lower max (10 mg/day) are commonly used.
- In anxiety-sensitive patients, some clinicians start 5 mg daily with slower titration to reduce early activation/jitteriness and insomnia.
- Gradual tapering can minimize discontinuation symptoms.
- When discontinuation symptoms occur despite tapering, extending the taper interval (smaller steps over longer periods) is often better tolerated than abrupt pauses or rapid reductions.
Monitoring & Labs
- Suicidality and psychiatric activation (anxiety, agitation, mood elevation) during initiation and dose changes, especially in younger patients.
- Sodium in older adults or patients on diuretics if symptoms suggest hyponatremia.
- Bleeding/bruising risk when combined with NSAIDs, antiplatelets, or anticoagulants; reinforce early symptom reporting.
- Medication reconciliation to avoid serotonergic combinations and to anticipate washout needs during antidepressant switching.
- ECG when cardiac risk is present or when combining multiple QT-active medications, even though escitalopram’s QT effect is typically smaller than citalopram.
Escitalopram is generally low-interaction; the main “high-signal” risks are suicidality early in treatment, hyponatremia in older adults, and additive serotonin-syndrome risk when combined with other serotonergic agents overall in practice.
Adverse Effects
FDA boxed warnings
- Boxed warning: Increased suicidality risk in young adults—closer monitoring is common during initiation.
Common side effects (≥10%)
- Nausea: Most common adverse event.
- Somnolence or insomnia: Dose timing is often adjusted.
- Sexual dysfunction: Management strategies can be discussed if persistent.
- Sweating: Hydration can become a practical issue.
Other notable effects
- Hyponatremia (SIADH) risk, particularly in elderly; sodium monitoring is common in higher-risk patients.
- QT prolongation minimal at 20 mg/day but caution with other QT-active agents.
- Discontinuation symptoms can occur if stopped abruptly (dizziness, paresthesias, irritability); tapering tends to be better tolerated than sudden discontinuation.
- Bleeding risk can increase when combined with NSAIDs, antiplatelets, or anticoagulants; counseling often covers bruising and GI bleeding symptoms.
- Mania/hypomania can emerge in bipolar-spectrum illness; coordinate prevention strategies via the bipolar disorder hub when antidepressants are part of a regimen.
Interactions
- Contraindicated with MAOIs; observe washout periods are required.
- Weak CYP2D6 inhibitor—coadministered CYP2D6 substrates may warrant monitoring.
- Additive bleeding risk with NSAIDs/anticoagulants.
- Caution is common with other serotonergic agents (triptans, tramadol, linezolid) that can raise serotonin syndrome risk.
Other Useful Information
- Mood and suicidality are commonly reassessed during early therapy and dose changes.
- Counseling often covers recognizing serotonin syndrome and discontinuation symptoms.
- Measurement-based follow-up (e.g., PHQ-9, GAD-7) can support treatment adjustments; medication is often paired with psychotherapy/skills-based interventions when available.
- Clarify treatment targets (sleep, panic frequency, functioning) early; it helps distinguish partial response from side effects when doses change.
- If early activation or insomnia occurs, slower titration and consistent dosing time are often better tolerated than rapid dose changes.